Study Finds Phototherapy Is More Cost Effective Than Biologics and More

Phototherapy Is More Cost Effective Than Biologics
Prescribing phototherapy instead of biologics for the treatment of psoriasis could potentially be a significant cost saving for patients, according to a poster presentation by Shors et al at the American Academy of Dermatology 72nd Annual Meeting in March.

Andrew Shors, MD, MPh, Group Health Cooperative, Seattle, WA, and colleagues assessed the economic burden of psoriasis as well as certain common psoriasis treatments. Dr. Shors and colleagues conducted the first population-based analysis of incremental cost of prevalent psoriasis that uses clinical information drawn from electronic medical records. Researchers estimated psoriasis attributable healthcare costs for all adults age ≥18 that were continuously enrolled in the studies health plan and received diagnoses of psoriasis during 2012.  

To establish the incremental costs attributable to psoriasis, researchers identified an adjusted-control group of patients without the diagnoses of psoriasis. Using regression models to estimate psoriasis attributable healthcare costs, a mean cost value was produced for psoriasis patients, non-psoriasis patients and each treatment category.  This allowed researchers to test for differences in healthcare costs.
The study included 2,986 patients who met the criteria and had ≥2 diagnoses of psoriasis in 2012. The sample consisted of 55.4% women and the mean age was 50.5. The mean adjusted total annual cost healthcare cost for patients diagnosed with psoriasis during 2012 was $10,816 compared to $6,772 for the control group. The incremental cost of $4,044 encounter by psoriasis patients is significant (P<.0001). Compared to all adults with a psoriasis diagnoses, patients treated with phototherapy experienced incremental costs of $3,910 (P<.0001). Psoriasis patients treated with biologic agents experienced incremental costs of $8,118 (P<.0001) relative to patients treated with phototherapy. The overall incremental cost experienced by patients prescribed biologic treatments was $12,029 (P<.0001) more than all adults diagnosed with psoriasis.

Substantial incremental costs were associated with treating adults with psoriasis. There were also significant costs associated with biologic treatments relative to phototherapy. The study provides evidence that physicians could lessen the economic burden placed on psoriasis patients by prescribing phototherapy as a treatment rather than biologic agents, according to the researchers.

Shors A, MD, Williams L, Fishman P. Cost of prevalent psoriasis. J Am Acad Dermatol. 2014;70(5 suppl 1):AB80.

Oxidation Reduction Critical for the Resolution of Psoriatic Plaques
phototherapyNarrowband UVB (NB-UVB) phototherapy is used for treatment of psoriasis, though the mechanisms underlying its efficacy are unclear. In a recent study, researchers used gene expression profiling to characterize gene expression in lesional epidermis from psoriasis patients in the middle and late stages of NB-UVB phototherapy. The earliest response to phototherapy was increased melanogenesis gene expression.

At the conclusion of treatment, genes responding to phototherapy and correlated to treatment outcome were involved in oxidation reduction, growth and mitochondria organization. They found that SPATA18, a key regulator of mitochondrial quality, was significantly down regulated in psoriasis (P<0.05). Poly(dA:dT) and poly(I:C) stimulation increased SPATA18 level in primary keratinocytes, indicating the importance of mitochondria quality control under innate immune induced oxidative stress.

“Normalized SPATA18 expression after phototherapy indicates improved mitochondrial quality control and restored cellular redox status. Our data suggest that oxidation reduction is critical for the resolution of psoriatic plaques following NB-UVB phototherapy,” they concluded.

Gu X, Nylander E, Coates PJ, Nylander K. Oxidation reduction is a key process for successful treatment of psoriasis by narrow-band UVB phototherapy. Acta Derm Venereol. Published online ahead of print June 5, 2014.

Study Examines Aminolevulinic Acid Photodynamic Therapy for Psoriasis
psoriasisA recent study examined the clinical evidence related to photodynamic therapy for psoriasis, which showed promise in the early 1990s as a treatment of plaque clearance following topical aminolevulinic acid-photodynamic therapy (ALA-PDT). In December 2013, the researchers conducted a systematic search of the PubMed Medline database using the keywords “psoriasis” and “photodynamic therapy.”

They found that numerous clinical studies failed to demonstrate a consistent, efficacious response to topical ALA-PDT. In addition, severe pain and often intolerable burning sensations were repeatedly reported. Therefore, the researchers concluded that the variability in clinical response and the painful side effects have made topical ALA-PDT an unsuitable treatment option for chronic plaque psoriasis. Nonetheless, early clinical studies of other modalities such as topical hypericin and methylene blue, as well as systemic ALA and verteporfin, have shown that these photosensitizers are efficacious and much better tolerated than topical ALA.

“With the current landscape of phototherapy dominated by psoralen combined with ultraviolet A (PUVA) and narrowband ultraviolet B (NB-UVB), an alternative light therapy utilizing the visible spectrum is certainly promising and a worthwhile endeavor to pursue,” they concluded.

Choi YM, Adelzadeh L, Wu JJ. Photodynamic therapy for psoriasis. J Dermatolog Treat. Published online ahead of print June 17, 2014.

Multiple Cycles of Phototherapy Yield Shorter Remission Periods
A recent study found that psoriasis patients who have previously undergone multiple phototherapy treatments experience shorter remission periods when being treated with narrowband ultraviolet B (NB-UVB) phototherapy.
Ryu et al conducted a study to determine the duration of remission periods experienced by psoriasis patients after NB-UVB, with a focus on patients who received multiple cycles of treatment.
The study included 63 patients who showed improvement after NB-UVB phototherapy. The researchers defined the remission period as the duration of time from the end of a phototherapy treatment cycle until treatment using phototherapy or systemic treatments was required again.
The study found that ≥3 phototherapy cycles within 6 months of systemic therapy is significantly associated with shorter remission times, particularly in patients ≥60 years of age. A multivariate analysis confirmed that ≥3 phototherapy cycles (odds ratio [OR], 4; 95% confidence interval [CI], 1.73-9.33; P=.001) and a history of systemic therapy (OR, 2.2; 95% CI, 1.27-3.95; P=.005) were independently associated with short remission times.
These findings indicate that the more phototherapy a psoriasis patient is exposed to, the less effective NB-UVB phototherapy may become for remission time, they concluded. The researchers suggested clinicians consider these findings when contemplating NB-UVB on psoriasis patients that have undergone multiple phototherapy treatments.

Ryu HH, Choe YS, Jo S, Youn JI, Jo SJ. Remission period in psoriasis after multiple cycles of narrowband ultraviolet B phototherapy.  J Dermatol. 2014;41(7):622-627.

Clear Skin a Clinical Distinction in QOL with Psoriasis  
Significant differences in quality of life (QOL) and use of prescription topical medication exist between patients with clear skin compared to patients with almost clear skin, ultimately suggesting that clear skin is the indicator of the level of psoriasis severity.
Junko Takeshita, MD, PhD, and colleagues found there is little evidence to determine the treatment goals of moderate-to-severe psoriasis. The team conducted a study to determine the Dermatology Life Quality Index scores and prescription topical medication use between patients with clear skin compared to those without clear skin.
The multicenter, cross-sectional analysis included 441 patients with almost clear skin and 97 patients with clear skin currently receiving phototherapy or systemic therapy for plaque psoriasis.
Patients with clear skin compared to patients with almost clear skin were more likely to note no impact of psoriasis on QOL (relative risk, 1.6; 95% confidence interval [CI], 1.37-1.86). Plaque psoriasis patients with clear skin compared to almost clear skin were more likely to report there was no use of prescription topical medication in the preceding week (relative risk, 2.08; 95% CI, 1.73-2.49).
The researchers noted one study limitation. Because the researchers utilized a cross-sectional analysis, it prohibited longitudinal assessment of psoriasis patient outcomes.
The differences in QOL and the use of prescribed topical medication of psoriasis patients who reported clear skin compared to patients who reported almost clear skin was significant. The results suggest that a clinical difference between moderate psoriasis and severe psoriasis may be the attainment of clear skin.

Takeshita J, Callis Duffin K, Shin DB, et al. Patient-reported outcomes for psoriasis patients with clear versus almost clear skin in the clinical setting. J Am Acad Dermatol. Published online ahead of print June 10, 2014.