Cost-effectiveness of moderate-to-severe psoriasis treatment

Incidence and Risk Factors of Hepatic Fibrosis in Psoriatic Patients Receiving Methotrexate with Concomitant Acitretin Therapy and Methotrexate Monotherapy

Background

The use of methotrexate-acitretin (MTX-ACI) combination therapy in treating psoriasis has been limited due to concerns related to hepatic fibrosis. However, in vitro evidence revealed a protective effect of acitretin in methotrexate (MTX)-induced liver fibrosis.

Objective

This study aimed to compare the real-life incidence of hepatic fibrosis in patients with psoriasis receiving MTX-ACI and MTX monotherapy and to investigate factors associated with hepatic fibrosis in MTX-exposed patients.

Methods

A retrospective cohort study was conducted based on a real-life registry containing data on patients with psoriasis who were administered MTX-ACI or MTX between 2008 and 2019 and underwent transient elastography according to cumulative MTX dose of 1.0–1.5 g and/or 3.5–4.0 g. Time-to-event analysis was performed to determine the cumulative incidence, incidence rate, and factors potentially affecting the occurrence of hepatic fibrosis.

Results

Of the 160 patients, 32 (20%) were treated with MTX-ACI, and 128 (80%) with MTX alone. Four patients (12.5%) in MTX-ACI group and 21 (16.4%) in MTX group developed hepatic fibrosis (p = 0.59). There was no statistically significant difference in cumulative incidence (16% in MTX-ACI vs 17% in MTX, p = 0.89) and incidence rate (37 cases per 1000 person-year in MTX-ACI vs 23 cases per 1000 person-year in MTX; hazard ratio [HR] = 1.07; p = 0.90) of hepatic fibrosis between the two groups. Diabetes and obesity were identified as significant factors associated with hepatic fibrosis (adjusted HR = 2.40, 95% confidence interval [CI]: 1.05–5.51; p = 0.04 and adjusted HR = 3.28, 95% CI: 1.18–9.16; p = 0.02, respectively) regardless of the cumulative MTX dose.

Conclusion

The incidence of hepatic fibrosis in a real-life clinical situation, determined by transient elastography in patients with psoriasis receiving MTX-ACI, was not increased compared to those receiving MTX monotherapy. Type 2 diabetes mellitus and obesity were identified as risk factors of hepatic fibrosis; hence, patients with these factors receiving long-term MTX therapy should be regularly monitored for this particular event.

The efficacy of UVA1 phototherapy in psoriasis: Clinical and histological aspects

BACKGROUND

Although ultraviolet A1 (UVA1) phototherapy is available for nearly 30 years, only few studies have been conducted for plaque-type psoriasis.

OBJECTIVES

To determine the efficacy and safety of UVA1 phototherapy in psoriasis by assessing the clinical and histological outcomes.

METHODS

This open study enrolled 15 patients with moderate to severe plaque-type psoriasis. All of the patients had skin type IV. A whole-body UVA1 device consisting of 24 lamps, was irradiated at a medium dose of 50 J/cm² three-times weekly for 30 sessions. Topical and systemic psoriasis treatments were discontinued before and during treatment; patients could only use emollients and antihistamines until 1-month post-completion. Psoriasis Area and Severity Index (PASI) scores were determined at baseline; at sessions 10th, 20th and 30th; and 1 month after treatment. Four-millimetre punch biopsies were obtained from the same psoriasis lesion at baseline and session 30th. Changes in histopathological gradings and polymorphonuclear, lymphocyte and Langerhans cell numbers were monitored.

RESULTS

Twelve patients completed the study. The mean age was 41.3 years (range: 25-71). The median PASI scores at baseline, session 30th and 1-month post-treatment were 16 (8.2, 43.3), 11 (4.4, 43.3) and 9.2 (2.7, 36.4), respectively. Although the PASI scores had improved significantly by 1-month post-treatment (P = .006), the histological parameters demonstrated minimal changes. All patients tolerated the phototherapy well and the most common side effect was skin tanning.

CONCLUSIONS

While medium-dose UVA1 phototherapy demonstrated some efficacy in moderate to severe plaque-type psoriasis. However, it might not be an excellent choice.

Perceptions of U.S. dermatology residency program directors regarding the adequacy of phototherapy training during residency

BACKGROUND/PURPOSE

Phototherapy utilization has declined over the last 20 years despite its efficacy and cost-effectiveness. Adequacy of phototherapy training in residency may be a contributing factor. The purpose of this study was to evaluate perceptions of U.S. dermatology residency program directors (PDs) regarding the effectiveness of their programs' phototherapy training and what constitutes adequate phototherapy education.

METHODS

A questionnaire was sent to PDs to assess phototherapy training within their program; aspects such as dedicated time, exposure to different modalities, and barriers to resident education were surveyed. We assessed the statistical association between these aspects and the perception by PDs that a program's training was adequate. Statistical testing was reported using Fisher's exact tests.

RESULTS

A total of 42 PDs responded. Residency training in oral psoralen and ultraviolet A therapy (PUVA), home phototherapy, and excimer laser, respectively, is not provided in 19.0%, 31.0%, and 47.6% of programs. 38.1% of programs provide ≤5 hours of phototherapy training over 3 years of training. 59.5% of PDs cited lack of curriculum time as the most common barrier to phototherapy education. 19.0% of PDs reported completely adequate phototherapy training, which was significantly associated with inclusion of faculty-led didactics, assigned reading, or hands-on clinical training in the curriculum.

CONCLUSIONS

There is a mismatch between the resources devoted to phototherapy education and the need for dedicated training reported by PDs. Limited time is allocated to phototherapy training during dermatology residency, and a large majority of PDs do not feel that the phototherapy training offered is completely adequate.

Phototherapy of Psoriasis, a Chronic Inflammatory Skin Disease

Phototherapy is an effective treatment modality for several skin diseases which has been in use from the era of the Egyptians. Insight into its mode of action has gradually accumulated over the past decades. A crucial biological effect of ultraviolet radiation is the induction of apoptosis in T lymphocytes and in keratinocytes in the epidermis. Via this mechanism inflammation-induced pathological changes characteristic of psoriasis are counteracted.Phototherapy remains the only therapeutic option for certain patient groups where modification of the systemic immune reactions is contraindicated, such as by HIV, internal malignancy or pregnancy. UVB treatment is highly cost-effective, which is important in this age of increasing health care costs.

Biomedical and Market Issues Surrounding the Advent of Biosimilars

As the patents associated with the biologics are set to expire in the near future, a new type of therapy appears on the horizon, and it is quite similar to the biologics. This commentary examines the biomedical and market issues surrounding the advent of biosimilars.

Challenges and Solutions in Selecting Systemic Antipsoriatic Agents

More than nine treatment options are available in Canada for moderate to severe psoriasis vulgaris. The process of deciding on optimal systemic antipsoriatic therapy for individual patients is dependent on multiple factors, including medical contraindications, the risks and benefits of treatment, and patient values and preferences. This article addresses current challenges faced by both dermatologists and their patients in the process of selecting systemic antipsoriatic therapy. Informed shared decision making is a useful relational model to describe the interaction between dermatologists and psoriasis patients in the selection of best systemic antipsoriatic treatment. There are no systematic reviews inclusive of the spectrum of treatment options for moderate to severe psoriasis, including biologics. Current guidelines of care are of varying quality and provide disparate and conflicting recommendations. Shortcomings in facilitating informed choice include inadequate training, skills, and resources. There is an urgent need for a high-quality systematic review of systemic antipsoriatic agents that includes the biologics. The evidence from such a document can form the basis for rational clinical guidelines and policy and can provide the foundation for educational and counseling tools. Furthermore, to facilitate dialogue and values-based informed choice, the use of decision aids for patients may be useful in selection of the most appropriate therapy.

Burden of Moderate-to-Severe Plaque Psoriasis and New Therapeutic Approaches (Secukinumab): An Italian Perspective

Abstract

Psoriasis is a chronic immune-mediated inflammatory skin disease commonly categorized as mild, moderate, or severe. Moderate-to-severe psoriasis is associated with significant comorbidity and has been shown to severely impair quality of life. Moreover, psoriasis is associated with high costs, including those associated with treatment, which have increased recently with the inclusion of biological systemic agents (most recently secukinumab) as available treatment options. However, despite clear evidence of their value in the treatment of moderate-to-severe plaque psoriasis, in Italy access to the biological agents remains limited to dermatological centers originally involved in the Psocare network. The impact of secukinumab entry into the market in Italy is still to be determined, but we believe that it will be associated with significant changes in the way in which biological treatments for psoriasis are accessed and prescribed in Italy. It is noteworthy that in January 2015, the European Medicines Agency approved secukinumab as first-line systemic therapy in this indication.

Funding

Novartis, Italy.

Adherence, satisfaction and preferences for treatment in patients with psoriasis in the European Union: a systematic review of the literature

BACKGROUND AND OBJECTIVE

Adherence to treatment in patients with psoriasis is often poor. An investigation of patient preferences and satisfaction with treatment may be important, based on the expected correlation with therapy compliance. This paper aims to examine and describe the current literature on patient preferences, satisfaction and adherence to treatment for psoriasis in the European Union (EU).

METHODS

Electronic searches were conducted using PubMed, ISI Web of Knowledge, Scopus, Spanish databases and Google Scholar. European studies published in English or Spanish between January 1, 2009 and December 31, 2014 regarding patient-reported outcomes in psoriatic patients were included. Studies conducted in non-EU countries, letters to the editor, editorials, experts' opinions, case studies, congress proceedings, publications that did not differentiate between patients with psoriasis and psoriatic arthritis or studies related to specific treatment were excluded.

RESULTS

A total of 1,769 titles were identified, of which 1,636 were excluded as they were duplicates or did not provide any relevant information. After a full-text reading and application of the inclusion/exclusion criteria, 46 publications were included. This paper will describe publications on adherence (n=4), preferences (n=5) and satisfaction with treatment (n=7). Results related to health-related quality of life articles (n=30) have been published elsewhere. Adherence rates are generally low in psoriasis patients regardless of the type of treatment, severity of disease or methods used to measure adherence. Biologic therapy is associated with greater clinical improvement. There is a direct association between physician recommendations, patient preferences and several domains of treatment satisfaction.

CONCLUSION

The results of this review support the conclusion that adherence rates in patients with psoriasis are suboptimal and highlight the need to improve patient compliance and satisfaction with treatment. Patients' preferences should be taken into account in the treatment decision-making process in order to improve patients' clinical outcomes by ensuring satisfaction and adherence.

Phototherapy in dermatology: A call for action

Of the wide range of treatment modalities available to dermatologists, few possess the history, efficacy, and safety of phototherapy. It should be emphasized that dermatologists are the only group of physicians optimally trained and qualified to understand the medical indications of phototherapy. Phototherapy, recognized for its cost-effectiveness, should remain a consideration in patient treatment. Continued training and education in residency and thereafter is needed to maintain the proficiency of physicians. In addition, payors need continued education to ensure that insurance coverage of phototherapy is not a barrier for patients to access this therapy. To further improve and optimize the outcome, phototherapy research needs to be supported.

The cost effectiveness of biologic therapy for the treatment of chronic plaque psoriasis in real practice settings in Italy

BACKGROUND AND OBJECTIVES

Biologic therapies are considered to be cost effective by leading Health Technology Assessment (HTA) agencies and, therefore, eligible for reimbursement by public health services. However, biologic therapies entail sizable incremental costs and, besides, have a considerable financial impact that in Italy amounts to 13.7 % of the national health service's pharmaceutical expenditure. In the reimbursability decision process, an important role is played by both the drug efficacy data observed in pre-licensing RCTs and the economic modelling assumptions, as they give evidence on cost effectiveness. The administration of therapies in real practice settings is likely to produce a significant deviation from the results predicted by the models, theoretically outweighing the assumption on which the decision process is founded. This is a matter of concern for public health services and, consequently, an interesting topic to investigate.

METHODS

To overcome the lack of knowledge concerning the actual cost effectiveness of biologic therapies for the treatment of plaque psoriasis in the clinical practice setting in Italy, an observational study was conducted in 12 specialist centres on patients switching to biologic therapy within a 6-month enrolment window.

RESULTS

The study confirms in clinical practice the efficacy of the switch to biologic therapies, analysed using a number of clinical [Psoriasis Area and Severity Index (PASI), pain visual analogue scale (VAS) and itching VAS] and quality-of-life parameters. A general health-related quality of life (HR-QOL) improvement, with a 0.23 quality-adjusted life-year (QALY) mean gain per patient, has been reported in the 6-month observation period. The direct medical costs to treat plaque psoriasis with biologic therapies amount to <euro>15,073.7 per year (prior to their enrolment, the same patients cost <euro>2,166.2 on an annual basis). After the switch to biologic agents, the cost per QALY during the first year of treatment amounts to <euro>28,656.3.

CONCLUSION

At least in the short-term, the clinical practice of the specialised Italian centres taking part in the study confirms that switching patients to a biologic drug produces an incremental cost-effectiveness ratio comparable with the values predicted by the HTA bodies.

The TNFRSF1B rs1061622 polymorphism (p.M196R) is associated with biological drug outcome in Psoriasis patients

Genetic factors are involved not only in the overall risk of suffering psoriasis, but also in their clinical characteristics and eventually in drug outcome. Biological therapies have dramatically improved the prognosis of Psoriasis. However, these treatments are very expensive and patients often exhibit a heterogeneous response that could be partially attributed to their genetic background. Thus, the research for genetic markers in psoriatic patients that could predict a poor response to biological therapies is an important issue. Our aim was to evaluate the effect of DNA variants at the "TNFα pathway" that could affect the risk of developing Psoriasis or the response to biological therapies among these patients. The genetic association study included a total of 518 Psoriatic patients and 480 healthy controls. Ninety of these patients received biological treatment and based on the change in the PASI score after 24 weeks were classified as good (PASI score ≥75%), intermediate (PASI 50-75), and non-responders (PASI <50). Next generation sequencing (NGS) with semiconductor-array technology was used to identify the nucleotide variants in the TNF α, TNFRSF1A and TNFRSF1B, and we only found three missense amino acid changes, all in TNFRSF1B. Interestingly, we found a significantly higher frequency of rs1061622 G carriers among CW6-positive patients (p = 0.004; OR = 1.69, 95% CI = 1.18-2.41). Allele G (p.196R) carriers were significantly more frequent in the non-responder group (56%) (p = 0.05). In conclusion, we report a significant association between the TNFRSF1B p.M196R variant and the risk for psoriasis and the response to treatment with anti-TNF or anti-Il-12/Il-23. The genotyping of this polymorphism could help to optimize the treatment by identifying patients with a likely poor response to biological drugs.

The cost of biologics for psoriasis is increasing

Background:

Biologic agents have revolutionized the management of psoriasis but at a higher cost compared with “traditional” agents. Cost must be considered when evaluating management options for psoriasis.

Objective:

To estimate the annual cost of treatment of psoriasis using biologic agents and assess the trend over the past decade.

Methods:

The cost of annual treatment paradigms for etanercept, adalimumab, and ustekinumab was estimated using the average wholesale price. Trends were assessed by calculating the percentage change in annual cost compared with the previous year. A sales-based cost of drugs was estimated using gross US sales of each drug and an estimate of the total number of patients treated based on prescription data.

Results:

The cost of one year of induction and maintenance treatment was highest for ustekinumab ($53,909), followed by etanercept ($46,395), and adalimumab ($39,041). The sales-based cost of drugs was greatest for ustekinumab ($25,012), then adalimumab ($6,786) and etanercept ($6,629). Sales-based cost increased at an average of 20% per year.

Conclusion:

The cost of biologic treatments for psoriasis has been increasing. Cost considerations in the management of psoriasis are likely to increase given the limited healthcare resources that are available.

Psoriasis causes significant economic burden to patients

INTRODUCTION

Psoriasis results in expenses to patients from many cost sources. Psoriasis treatments may result in considerable time and traveling costs, yet many studies fail to account for these costs. The objective of this study was to evaluate the multidimensional economic burden of psoriasis to patients.

METHODS

The study was based on 232 Finnish patients with psoriasis or psoriatic arthritis visiting a tertiary level dermatological clinic during a 1-year study period between October 1, 2009 and September 30, 2010. The data were based on a patient questionnaire, clinical data from the medical records and reimbursement data from the Finnish Social Insurance Institution. Item costs were based on true costs charged from the patients and all time cost estimates were based on the Human Capital Approach method.

RESULTS

199 patients with psoriasis and 33 with psoriatic arthritis were included in the study. Total costs were higher for patients receiving traditional systemic medications or phototherapy than those not receiving such treatment. Travel costs and travel time costs accounted for more than 60% of the costs of phototherapy. Skin care at home was time consuming and thus caused significant burden to patients. The majority of the visit costs arose from hospital visits and only a small proportion were attributed to visiting primary health care providers.

CONCLUSION

Visit charges and other patient co-payments were estimated to play a minor role in the total cost of psoriasis incurred by patients, while travel costs and lost time comprised the majority of the costs, which should not be omitted in future studies regarding costs of treatments.

Adherence to guidelines in the use of biological agents to treat psoriasis in Brazil

OBJECTIVE

In São Paolo, Brazil, patients can appeal to the courts, registering law suits against the government claiming the need for biological agents for treatment of psoriasis. If the lawsuits are successful, which is usually the case, the government then pays for the biologic agent. The extent to which the management of such patients, after gaining access to government payment for their biologic agents, adheres to authoritative guidelines, is uncertain.

METHODS

We identified patients through records of the State Health Secretariat of São Paulo from 2004 to 2011. We consulted guidelines from five countries and chose as standards only those recommendations that the guidelines uniformly endorsed. Pharmacy records provided data regarding biological use. Guidelines not only recommended biological agents only in patients with severe psoriasis who had failed to respond to topical and systemic therapies (eg, ciclosporin and methotrexate) but also yearly monitoring of blood counts and liver function.

RESULTS

Of 218 patients identified in the database, 3 did not meet eligibility criteria and 12 declined participation. Of the 203 patients interviewed, 91 were still using biological medicine; we established adherence to laboratory monitoring in these patients. In the total sample, management failed to meet standards of prior use of topical and systemic medication in 169 (83.2%) patients. Of the 91 patients using biological medicine at the time of the survey, 23 (25.2%) did not undergo appropriate laboratory tests.

CONCLUSIONS

Important discrepancies exist between clinical practice and the recommendations of guidelines in the management of plaintiffs using biological drugs to treat psoriasis.

The costs of psoriasis medications

Introduction

Psoriasis is a chronic disease, which contributes to the economic burden on health care. The distribution of psoriasis medication costs and the quality of life in these patients has been estimated to be around 20% of total costs.

Objectives

To estimate the economic distribution of medications and the impact of multiple treatment options on a patient’s quality of life.

Materials and methods

The study was based on 236 Finnish psoriasis patients. The Finnish Social Insurance Institution had databases for all psoriasis related medications purchased. Each purchase, during the 1-year study period (1 October 2009–30 September 2010), was recorded and analyzed. The dermatological quality-of-life index was collected from the medical records.

Results

Total medication costs were €1,083 per year per patient. Topical treatments were the most often purchased medication and they comprised 18% of the total medication costs. Ten percent of the patients needed 3 or more medication changes during the 1-year study period. Biologics were used only by 5% of patients, but they produced 67% of total medication costs. Patients needing various treatments had higher medication costs and a poorer quality of life.

Conclusion

A small number of patients generated a great sum of medication costs partly due to the need to change medications. These patients had the worst quality-of-life index scores. Biologics formed a major cost component.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-013-0040-z) contains supplementary material, which is available to authorized users.

Cost effectiveness of moderate to severe psoriasis therapy with etanercept and ustekinumab in the United States

BACKGROUND

Limited information is available on the cost effectiveness of ustekinumab and alternative biologic treatments in a United States (US) setting. Given the recent head-to-head clinical trial study of ustekinumab and etanercept, an economic model comparing the two treatments can be constructed. Etanercept and ustekinumab are indicated for the treatment of chronic moderate to severe plaque psoriasis in adult patients who are candidates for phototherapy or systemic therapy.

OBJECTIVE

Clinical trials have evaluated the efficacy of ustekinumab, an anti-cytokine biologic, for the treatment of moderate to severe psoriasis. This study evaluated the cost effectiveness of ustekinumab compared with etanercept from a US societal perspective.

METHODS

A Markov model was constructed to simulate the incremental cost per quality-adjusted life-year (QALY) gained every 12 weeks over a base-case 3-year time horizon. A hypothetical patient cohort was based on the characteristics of the phase III Active Comparator Psoriasis Trial (ACCEPT). The main outcome measures were costs and QALYs, which were estimated from the US societal perspective. Costs, utilities, treatment strategy, and resource use estimates were obtained from relevant literature. All costs were adjusted to 2011 US dollars. A 3 % annual discount rate was applied to costs and QALYs. Incremental cost-effectiveness ratios were in US dollars per QALY gained.

RESULTS

For the base-case 3-year time horizon, the incremental cost-effectiveness ratio comparing ustekinumab 90 mg with etanercept 50 mg was US$384,401 per QALY gained. Ustekinumab 45 mg dominates etanercept 50 mg for the same time horizon. These results were robust to sensitivity analyses involving treatment strategy, transition probabilities, valuing outcomes, and resource use and costs. The probabilistic sensitivity analysis suggests ustekinumab 90 mg has a minimal (4 %) chance of being cost effective compared with etanercept 50 mg at a willingness-to-pay threshold of US$150,000 per QALY improvement. For the same threshold, ustekinumab 45 mg has a high (88 %) chance of being cost effective compared with etanercept 50 mg.

CONCLUSION

Under typical US willingness-to-pay cutoffs, ustekinumab 90 mg is not cost effective compared with etanercept 50 mg therapy in moderate to severe psoriasis patients for the base-case 3-year time horizon. Ustekinumab 45 mg dominates etanercept 50 mg therapy for an equivalent patient psoriasis severity and time horizon.

Cost effectiveness of biologic therapies for plaque psoriasis

BACKGROUND

During the last decade, the implementation of biologic agents has changed the therapeutic management of severe psoriasis. Biologic agents have clinically proven efficacy, but their use is associated with a much higher cost compared with traditional treatment options. Therefore, when assessing the use of these drugs for the treatment of psoriasis, it is important to consider their cost effectiveness.

OBJECTIVE

The objective of this study was to determine and compare the cost effectiveness of biologic agents with regard to the cost per patient achieving a minimally important difference (MID) in the Dermatology Life Quality Index (DLQI) and the cost per patient achieving a 75% improvement in the Psoriasis Area Severity Index (PASI-75).

METHODS

A PubMed literature search was conducted to identify studies describing the efficacy of all currently US FDA-approved biologic therapies. The cost effectiveness of each agent over a 12-week period was determined and a sensitivity analysis was performed. Based on clinical efficacy at 12 weeks, treatment paradigms were extrapolated to estimate cost-effectiveness ratios after 1 year of treatment. Pooled data on each biologic agent at different doses were compared in a one-way sensitivity analysis and in an extreme case scenario analysis.

RESULTS

Twenty-seven studies were included in the analysis. Intravenous (IV) infliximab 3 mg/kg was the most cost-effective biologic agent with respect to both the cost per patient achieving PASI-75 and the cost per patient achieving a DLQI MID. The next most cost-effective agents in terms of cost per patient achieving PASI-75 were subcutaneous (SQ) adalimumab 40 mg administered every other week (eow) after an 80-mg loading dose, SQ adalimumab 40 mg eow, and IV infliximab 5 mg/kg. In terms of cost per patient achieving DLQI MID, IV infliximab 5 mg/kg, SQ etanercept 25 mg once weekly, SQ etanercept 50 mg once weekly, and SQ adalimumab 50 mg eow after an 80-mg loading dose were the next most cost-effective agents behind IV infliximab 3 mg/kg. For both costs per patient achieving DLQI MID and PASI-75, alefacept was the least cost-effective agent up to a 10% level of variation at all doses except 0.025 mg/kg once weekly.

LIMITATIONS

This study was limited by the use of efficacy data from 12-week clinical trials that did not compare treatments head to head to determine relative efficacy and may not be generalizable to longer treatment periods. Additionally, the estimated cost of treatment did not take into account indirect costs or variations in costs due to insurance company price contracting.

CONCLUSIONS

Biologic treatments that were most cost effective were so in respect to both the cost per patient achieving DLQI MID and per patient achieving PASI-75. This suggests that the same agents that are effectively clearing the disease are also effective in improving the patients' subjective assessment of dermatology-related quality of life.

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.

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.

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the American Academy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients' needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

UV-based therapy and vitamin D

The ultraviolet (UV) light spectrum has long been known to induce biologic effect on the skin. For a large number of cutaneous disorders, phototherapy and photochemotherapy are effective therapeutic options with excellent safety profiles and well-documented side effects. Despite their ease of administration and benefits, phototherapeutic treatment modalities require appropriate space for the equipment, trained staff, and patient education prior to initiating treatment. However, when the initial barriers to treatment can be overcome, UV therapy can offer patients significant relief from their cutaneous disease. Furthermore, UVB-based phototherapy can produce significant alteration to vitamin D levels. With the recent research implicating association of low vitamin D levels with a variety of health conditions, whether patients receiving phototherapy or, more specifically, those getting vitamin D supplement may be protected from these diseases remains to be established.

Ten years of infliximab: its role in dermatology

Psoriasis is a common chronic inflammatory disease of the skin. Psoriatic arthritis may develop in about 20% of psoriasis patients while metabolic syndrome is a frequent comorbidity, and risk of cardiovascular disease is increased in psoriasis patients. Classical systemic treatments have not evolved much during the last decades; biological therapies on the contrary have added most significant progress in systemic treatment during the last 10 years. In particular tumor necrosis factor (TNF) blockade has changed the treatment outcomes in moderate to severe psoriasis patients. With drugs such as infliximab treatment goals of 75% improvement of psoriasis lesions together with significant improvement of quality of life can be achieved. Furthermore, skin clearance is possible in many patients with continued maintenance treatment with infliximab. More recent pivotal studies have shown that associated nail psoriasis responds well to infliximab, an outcome that was difficult to reach with classical therapies. There is good evidence that infliximab may be useful in other dermatological conditions such as pyoderma gangrenosum and hidradenitis suppurativa. Infliximab is an intravenous administration over a 2-hour period. Some patients may develop infusion reactions, and dermatologists need to be well aware of any possible adverse events that may be associated with anti-TNF treatment. Today, dermatologists have collected a broad experience with infliximab treatment of psoriasis and they have thus advanced their clinical practice accordingly.