Home ultraviolet light therapy for psoriasis: why patients choose other options.

BACKGROUND: Psoriasis is a common inflammatory skin condition for which office-based and home phototherapy are safe and effective treatments. However, patients who are prescribed home phototherapy devices often choose other treatment options. OBJECTIVE: To determine the reasons why patients do not purchase a home phototherapy device after it has been recommended and prescribed by their physician. METHODS: Patients who were written a prescription for a home phototherapy device but did not fill the prescription were identified and contacted by the National Biological Corporation to participate in a telephone survey consisting of 4 questions regarding why they did not pursue a prescribed home ultraviolet device and how they were currently treating their psoriasis. RESULTS: The most common reason for not obtaining the prescribed home phototherapy device was using a biologic agent (31%). The second and third most frequently reported reasons were "cost share too high" and "insurance will not cover" (18% and 17%, respectively), together accounting for 35%. LIMITATIONS: The reason why patients were prescribed biologics while having an unfilled home phototherapy device prescription was not obtained. CONCLUSIONS: Out of pocket cost is a significant barrier to home phototherapy, even to patients who are well insured.

Explicit and implicit copayments for phototherapy: examining the cost of commuting.

BACKGROUND: Whereas phototherapy is a safe and cost-effective treatment modality for psoriasis, economic disincentives discourage its use, including both direct and indirect costs to the patient. PURPOSE: To determine when it may be cost-effective for patients to purchase a home light unit versus driving to clinic for outpatient phototherapy sessions. METHODS: Estimates of expenses associated with 3 months of outpatient phototherapy were determined and compared to the price of a home phototherapy unit. Factors examined included the cost of gasoline (based on the national average), fuel efficiency of the vehicle, cost of owning and operating a motor vehicle, lost wages, and copayments. RESULTS: The cost for a standard 6-bulb narrowband UVB home unit is approximately $2600. Direct and indirect expenses imposed on patients increase with distance travelled to the dermatologist. If a patient lives 20 or more miles away from the dermatologist, the expenses associated with travel can total more than the out of pocket expense of purchasing a home phototherapy unit. LIMITATIONS: This small analysis only accounted for the first 3 months of treatment and likely underestimates the total costs that patients would experience over a lifetime of treatment. CONCLUSIONS: It may be beneficial for physicians to educate patients on the cost-burden of in-office versus home phototherapy because patients can use these parameters to determine which option would be more cost-effective for them.

A double-blind, randomized clinical trial of 20% alpha/poly hydroxy acid cream to reduce scaling of lesions associated with moderate, chronic plaque psoriasis.

BACKGROUND: Salicylic acid is a topical keratolytic agent used to reduce scaling and hyperkeratosis associated with psoriasis vulgaris. However, its use is limited due to potential systemic toxicity. Hydroxyacids also modulate keratinization and desquamation. Therefore, they may serve a beneficial role in the treatment of hyperkeratotic conditions. To date, there are no clinical studies in the literature regarding the efficacy of hydroxyacids for psoriasis treatment. PURPOSE: To evaluate the therapeutic efficacy of topical 20% alpha-hydroxy/polyhydroxy acid versus standard salicylic acid to reduce scaling in patients with moderate, chronic psoriasis. METHODS: Twenty-five subjects with moderate, chronic psoriasis were enrolled in a 2-week, double-blind, left-right, randomized, bilateral comparison clinical trial to compare the efficacy of 20% alpha-hydroxy/polyhydroxy acid emollient versus 6% salicylic acid cream and 24 were randomized/completed. Clinical evaluations to assess the severity of psoriasis and scaling were performed using a 6-point scale prior to treatment, as well as following 1 and 2 weeks of therapy. RESULTS: Twenty-four participants completed the study. Both 20% alpha-hydroxy/polyhydroxy acid emollient and 6% salicylic acid cream were efficacious in reducing scale of psoriatic lesions. The topical 20% alpha-hydroxy/polyhydroxyacid reduced scaling at a faster rate; however, following 2 weeks of treatment the efficacy of both products were relatively the same. CONCLUSION: 20% alpha-hydroxy/polyhydroxyacid is as efficacious as salicylic acid in regards to the de-scaling of psoriatic plaques. Additionally, 20% alpha-hydroxy/polyhydroxyacid cream may yield quicker results and less toxicity than salicylic acid.

Patterns of vitamin D analog use for the treatment of psoriasis.

BACKGROUND: Psoriasis is a chronic disease that significantly impacts patients' quality of life. It most commonly manifests as localized disease, for which there are various treatment options. OBJECTIVE: To determine the prescription patterns of topical corticosteroids and vitamin D analogs for the treatment of psoriasis in the United States and how their use has changed over time. METHODS: Data from the National Ambulatory Medical Care Survey (NAMCS) from 1994 to 2010 were queried for visits linked with a psoriasis diagnosis. Prescriptions for topical corticosteroids and vitamin D analogs were described. Vitamin D analogs usage was compared across physician specialties. For each sampled visit reported in the NAMCS, visits meeting our inclusion criteria that also mentioned the following medications were identified: topical calcipotriene, topical calcipotriene/betamethasone or any topical corticosteroid indicated for the treatment of psoriasis. RESULTS: There were an estimated 2.05 million psoriasis visits per year over the 1994-2010 interval. Dermatologists were responsible for 67% of these encounters followed by family practice (14%) and internal medicine (11%). Dermatologists prescribed a vitamin D product at 15% of psoriasis visits, followed by family physicians at 12%, and internists at 5%. Dermatologists prescribed calcipotriene, calcipotriene/betamethasone, and topical corticosteroids in 15%, 4% and 59% of psoriasis visits, respectively. Over time, there was no significant change in the use of topical steroids or vitamin D products by physicians.This study is limited by the inability to determine the severity of psoriasis from the data collected, and the lack of data on the length of treatment with different medications. CONCLUSIONS: Despite their demonstrated efficacy and safer side effect profile, vitamin D analogs are used less often than topical corticosteroids for the treatment of psoriasis. These findings suggest that vitamin D products may not be utilized to their fullest potential as effective topical therapy or adjuncts to therapy for localized plaque psoriasis.

Skin manifestations of outpatient adverse drug events in the United States: a national analysis.

BACKGROUND: Cutaneous reactions to drugs are among the most common clinical manifestations of adverse drug events (ADEs); however, data on outpatient cutaneous adverse drug events (CADEs) are limited. PURPOSE: To provide national estimates of outpatient CADEs and determine their most frequent causes. METHODS: Outpatient CADEs recorded in the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1995 and 2005 were analyzed. The national incidence of outpatient CADEs in those seeking medical attention in the United States was estimated, and the common medication classes implicated with CADEs were identified. RESULTS: There were a mean annual total of 635,982 CADE-related visits, resulting in an annual incidence of 2.26 CADEs per 1,000 persons. Patients took an average of 2.2 medications in addition to the one causing the CADE. The incidence of CADEs increased with age, with a peak in the age group from 70 to 79 years. The medications most frequently causing a CADE were antimicrobial agents. Dermatitis and urticaria were the two main types of skin reactions reported. CONCLUSIONS: CADEs occur less frequently in outpatients than in inpatients and result in few hospital admissions. Physicians must be particularly cognizant of the occurrence of CADEs when prescribing antimicrobial agents.

Acitretin prescribing patterns in women of childbearing potential.

BACKGROUND: Acitretin is indicated for severe psoriasis, but it is also a potent teratogen whose use should be avoided in women of childbearing potential. Topical medications, phototherapy, cyclosporine A, and new biologic agents provide safer alternatives for women of childbearing age with moderate to severe psoriasis. PURPOSE: To determine the demographics of acitretin prescribing patterns as an assessment of acitretin use in women of child-bearing potential. METHODS: We examined National Ambulatory Medical Care Survey (NAMCS) data from the years 1990-2009 to determine demographic data on patients who were prescribed etretinate or acitretin. We used age under 50 as a proxy for childbearing potential. RESULTS: From 1996-2009, there were an estimated 29 million office visits for psoriasis. Females accounted for 14.3 million of these visits, and 6.5 million (45.6%) of them were under the age of 50. The NAMCS contained only one record of a female patient under the age of 50 being prescribed acitretin from 1996-2009, the years during which acitretin had been available in the United States. This corresponds to an estimated 2.3% of all psoriasis patients prescribed acitretin during this time (20,000 out of 890,000). LIMITATIONS: The NAMCS estimates national trends based on a large nationwide database. While the use of acitretin in women under 50 is low, the precision of the estimate is limited by the small sample size provided by this database. CONCLUSIONS: There are now many alternative treatments besides acitretin for women of childbearing potential with moderate to severe psoriasis. Acitretin is used at most infrequently in this population. In females of reproductive potential, acitretin should be reserved for non-pregnant patients who are unresponsive to other therapies or whose clinical condition contraindicates the use of other treatments.

Focusing and depth of field in photography: application in dermatology practice.

BACKGROUND: Conventional photography obtains a sharp image of objects within a given 'depth of field'; objects not within the depth of field are out of focus. In recent years, digital photography revolutionized the way pictures are taken, edited, and stored. However, digital photography does not result in a deeper depth of field or better focusing. METHODS: In this article, we briefly review the concept of depth of field and focus in photography as well as new technologies in this area. RESULTS: A deep depth of field is used to have more objects in focus; a shallow depth of field can emphasize a subject by blurring the foreground and background objects. The depth of field can be manipulated by adjusting the aperture size of the camera, with smaller apertures increasing the depth of field at the cost of lower levels of light capture. Light-field cameras are a new generation of digital cameras that offer several new features, including the ability to change the focus on any object in the image after taking the photograph. CONCLUSION: Understanding depth of field and camera technology helps dermatologists to capture their subjects in focus more efficiently.

Timing of return office visit affects adherence to topical treatment in patients with atopic dermatitis: an analysis of 5 studies.

Objective electronic monitoring systems have demonstrated poor adherence to topical therapies. We compared 5 clinical trials that measured adherence to topical therapy in patients with atopic dermatitis to identify characteristics of the study designs that affect patient adherence. Mean adherence among the trials ranged from 32% to 93%, and the length of time between baseline and first return visit was inversely proportional to adherence. The timing of the first return visit may be a practical tool to modify patient adherence.

Sleep disturbances in psoriasis.

BACKGROUND: Psoriasis negatively impacts sleep, but the factors that cause this sleep disturbance are not well characterized. PURPOSE: To assess sleep quality in subjects with psoriasis. METHODS: 35 outpatients diagnosed with chronic plaque psoriasis affecting at least 10 percent BSA and 44 controls completed the Pittsburgh Sleep Quality Index, Patient Health Questionnaire, Itch Severity Scale, Insomnia Severity Index, and Epworth Sleepiness Scale. For multiple testing, alpha was set at 0.008. RESULTS: Adjusting for age, BMI, and gender, patients with psoriasis had 4.3 times the odds to score in a higher insomnia category (OR 95% CI: 1.7, 11.2; p=0.01), a trend toward experiencing "poor sleep" (p=0.04), and no difference in odds to be "sleepy" (p=0.83). Patients with psoriasis had greater itch than those without psoriasis (mean ISS 8.5 vs. 2.0; p<0.0001). When adjusting for age, BMI, gender, and depression, those with psoriasis were not more likely to experience poor sleep quality (p=0.25), nor to score in a higher insomnia category (p=0.20) or be more "sleepy" (p=0.53). CONCLUSIONS: Patients with psoriasis suffer from sleep disturbances and pruritus more than those without psoriasis. Although sleep disturbances are more prevalent, this may be secondary to depression rather than related to a direct effect of psoriasis.

How good are US dermatologists at discriminating skin cancers? A number-needed-to-treat analysis.

BACKGROUND: Identification of skin cancer requires discrimination of malignant lesions from benign lesions. The number of biopsies performed to yield one cancer diagnosis can be presented as a number needed to treat (NNT), and provides an assessment of the efficiency of skin cancer detection. OBJECTIVE: To assess the clinical accuracy of US dermatologists screening for skin cancer, the NNT for both melanoma and non-melanoma skin cancer was examined. METHODS: Pathology reports from 2021 biopsies performed at the Wake Forest University Department of Dermatology were reviewed, including the physician's differential diagnosis and final pathological diagnosis. The NNT was calculated for melanoma, non-melanoma skin cancer, and all skin cancer diagnosed. RESULTS: Of 1240 biopsies suspicious for skin cancer, 559 cancers were diagnosed, yielding a NNT of 2.22 for any cancer. The NNT specifically for non-melanoma skin cancer was 1.6, while the NNT for melanoma was 15. Patient age, anatomical location, sex and physician all significantly impacted on NNT values. CONCLUSIONS: The NNT for melanoma in our study was lower compared to recently published values obtained from general practitioners in Australian skin cancer clinics (NNT of 30). Variability amongst institutions, practice settings and physicians supports the need to establish a benchmark NNT.

Trends in pediatric psoriasis outpatient health care delivery in the United States.

OBJECTIVE: To characterize patterns of childhood psoriasis health care delivery from 1979-2007. DESIGN: Retrospective, cross-sectional investigation using National Ambulatory Medical Care Survey data. SETTING: US ambulatory physician offices from 1979 through 2007. PATIENTS: Children with psoriasis ages 0 (birth) to 18 years. MAIN OUTCOME MEASURES: Demographics, physician specialty, and medications prescribed. RESULTS: There were an estimated 3.8 million visits for psoriasis over the study interval with a median of 123,420 visits per year. Dermatologists saw 63% of patients, pediatricians saw 17%, and internists, 14%. The numbers of visits were equal between sexes but ranged by age group: patients ages 13 to 18 years accounted for 47% of visits, those ages 8 to 12 years for 35%, and those ages 0 to 7 for 18%. Ninety-three percent of patients were white. Topical corticosteroids were the most commonly prescribed medications. Children 0 to 9 years old received equally potent corticosteroids as children 10 to 18 years old. Among all patients, the most prescribed medication was topical betamethasone; among those ages 0 to 9 years, tacrolimus; and among those ages 10 to 18 years, betamethasone. By physician specialty, the most prescribed medications were high-potency steroids for dermatologists and internists, and topical tacrolimus for pediatricians. Topical calcineurin inhibitors were not among the top 20 most prescribed medications by dermatologists, and systemic antipsoriatic agents were not among the top 20 most prescribed medications in any age group. CONCLUSIONS: Over the 28-year interval, outpatient visits for pediatric psoriasis were attended primarily by white children older than 8 years in equal number by sex. Dermatologists and pediatricians saw the majority, and treatment approach differed by physician specialty and patient age. Treatment guidelines for childhood psoriasis may help reduce treatment variability.

Topical antibiotic trends from 1993 to 2007: use of topical antibiotics for non-evidence-based indications.

BACKGROUND: Systemic antibiotic use has become more conservative with the emergence of drug resistance. Topical antibiotics are employed for a variety of indications, although there are only a few evidence-based indications. OBJECTIVE: To examine topical antibiotics use in the outpatient setting. METHODS: Topical antibiotic use was characterized using data from the 1993 to 2007 National Ambulatory Medical Care Survey. Visits were identified at which a topical antibiotic was used and analyzed according to patient demographics, diagnoses, procedures, concomitant medications, and provider specialty. Topical antibiotic use over time was analyzed using linear regression. RESULTS: The most frequent diagnoses associated with topical antibiotic use were benign or malignant neoplasm of skin, impetigo, insect bite, and cellulitis. Data revealed a significant downward trend in topical antibiotics associated with dermatologic surgery (p<.001) and a nonsignificant downward trend in use in conjunction with skin biopsies (p=.09). Topical antibiotic use by dermatologists was noted to be decreasing over time, whereas among non dermatologists, it was noted to be increasing, although neither of these trends was statistically significant. CONCLUSION: Topical antibiotics continue to be used for non-evidence-based indications, despite data that suggest that such use may be detrimental for patients and represents significant costs to the health care system. The authors have indicated no significant interest with commercial supporters.

Acitretin for the treatment of psoriasis: an assessment of national trends.

BACKGROUND: Combination therapy is a common and appropriate treatment strategy for moderate-to-severe psoriasis, as it provides for enhanced efficacy and decreased toxicity compared to the use of a single agent. Acitretin is an effective oral retinoid for psoriasis that seems to find its greatest value when complemented by other topical and systemic treatments. OBJECTIVE: The primary aim of this study is to assess the use of acitretin in combination with other treatments for psoriasis. METHODS: We assessed the use of acitretin for the treatment of psoriasis using nationally representative survey data from the National Ambulatory Medical Care Survey (NAMCS). RESULTS: Among visits where acitretin was listed in the NAMCS, other psoriasis medications were co-prescribed in 62 percent of visits. The co-prescribed medications included topical corticosteroids (51%), calcipotriene (31%), biologics (6%), cyclosporine (5%), methotrexate (5%) and tazarotene (2%). CONCLUSION: The use of acitretin in combination with other psoriasis treatments, particularly topical corticosteroids and calcipotriene, is a common practice. Acitretin is co-prescribed with the biologics, likely because of the relative lack of overlapping effects on immune function. The immune-sparing method of action of acitretin makes combination treatment with the systemic agents an attractive treatment option, especially in patients where further immunosuppression is unwarranted.

Acitretin in dermatology: a review.

INTRODUCTION: Acitretin is a systemic retinoid drug used in the treatment of severe psoriasis. It has also been used for a spectrum of other difficult-to-treat dermatoses, including hyperkeratotic and inflammatory dermatoses and non-melanoma skin cancers. Here we review the available data regarding both FDA-approved and off-label uses of acitretin, clinically relevant adverse events, precautions and monitoring. METHODS: A PubMed literature search was conducted utilizing the search term "acitretin," which yielded 714 hits. Results were further limited to English language clinical trials in human subjects. Of 78 articles evaluated for relevance, 60 were included for review. RESULTS: Acitretin is effective as monotherapy and in multidrug therapeutic regimens for the treatment of psoriasis and other hyperkeratotic and inflammatory disorders, as well as for malignancy chemoprevention. Its use is limited by its teratogenic potential and other adverse effects, including mucocutaneous effects and hepatotoxicity. Potential adverse effects may be reduced or avoided by using lower doses of acitretin or in combination with other therapies. LIMITATIONS: The reviewed studies include many small trials and case reports of the use of acitretin for psoriasis. Studies of acitretin therapy for the treatment of other cutaneous disorders are limited. CONCLUSION: Acitretin is a beneficial treatment for psoriasis, and should be considered when not contraindicated. Particularly when used in combination with ultraviolet (UV) phototherapy, is a safe and cost effective therapeutic strategy.

An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial.

BACKGROUND: Atopic dermatitis (AD) is a prevalent skin disorder with significant cost of treatment. Several prescription device moisturizers have been approved by the FDA to treat AD but are significantly more expensive than well-crafted over-the-counter (OTC) moisturizers. No studies have been performed to compare both the clinical efficacy and cost-efficacy of these prescription devices to OTC moisturizers. PURPOSE: The purpose of this study is to compare the clinical efficacy and cost-efficacy of a glycyrrhetinic acid-containing barrier repair cream (BRC-Gly, Atopiclair®), a ceramide-dominant barrier repair cream (BRC-Cer, EpiCeram®) and an OTC petroleum-based skin protectant moisturizer (OTC-Pet, Aquaphor Healing Ointment®) as monotherapy for mild-to-moderate AD in children. METHODS: Thirty-nine patients, age 2-17 years, with mild-to-moderate AD were randomized 1:1:1 to receive one of three treatments-BRC-Gly, BRC-Cer or OTC-Pet-with instructions to apply the treatment three times daily for three weeks. Disease severity and improvement was assessed at baseline and on days 7 and 21. RESULTS: No statistically significant difference for any efficacy assessment was found between the three groups at each time point. The OTC-Pet was found to be at least 47 times more cost-effective than BRC-Gly or BRC-Cer. LIMITATIONS: The relatively small sample size of 39 subjects was not sufficient to establish OTC-Pet as superior treatment in AD. CONCLUSIONS: OTC-Pet is as effective in treating mild-to-moderate AD as both BRC-Gly and BRC-Cer and is at least 47 times more cost-effective. NAME OF REGISTRY: II-AF-ATD-Aquaphor, Comparing the Efficacy and Cost-Effectiveness of Aquaphor to Atopiclair and EpiCeram in Children with Mild to Moderate Atopic Dermatitis. REGISTRATION IDENTIFIER: NCT01093469.

A review of phototherapy protocols for psoriasis treatment.

Phototherapy is a mainstay in the treatment of psoriasis and is available as psoralen plus UVA (PUVA), broadband UVB (BB-UVB), and narrowband UVB (NB-UVB). Phototherapy can be administered in the hospital, outpatient clinic, or in the patient's home. The purpose of this review is to provide some practical guidance to general dermatologists and residents on the specifics of using phototherapy, which, despite its decreasing use, remains one of our most safe and effective treatment strategies for psoriasis care. We conducted a literature review of home phototherapy, BB-UVB, NB-UVB, and PUVA phototherapy using PubMed, MD Consult, and reference lists. A variety of protocols for BB-UVB, NB-UVB, and PUVA have been used in clinical trials. NB-UVB is more effective than BB-UVB and safer than PUVA. Typical regimens for NB-UVB involve dosing 3 times per week for at least 3 months. Treatment must be independently developed to suit each participant's needs. Ultraviolet light is an effective, relatively safe modality that is a valuable tool in the treatment of psoriasis. NB-UVB phototherapy is considered the first-line treatment for extensive plaque type psoriasis.

Trends in home phototherapy adoption in the US: monetary disincentives are only the tip of the iceberg.

There are often multiple hurdles that must be crossed to obtain home phototherapy devices. To identify these obstacles, we examined survey data from the National Biological Corporation on patients who never acquired a home unit after being given a prescription from their doctors. Additionally, physicians' prescribing patterns were assessed from data gathered by IMS Health. Physician education of and willingness to prescribe home phototherapy was assessed via a survey distributed at the 9th Annual Dermatology Chief Residents' Meeting. When psoriasis patients were written a prescription for home phototherapy, less than half acquired a unit. Most patients (72%) stated that they did not get a unit secondarily to the high out-of-pocket expenses. In 2006, dermatologists wrote 94,385 new scripts for etanercept, compared with only 1073 scripts for home phototherapy. Very few (35%) dermatology residents receive formal training on home phototherapy. When it comes to the reasons behind patients receiving significantly more expensive biologics instead of home phototherapy for their psoriasis, high copays and deductibles are just the tip of the iceberg. It is likely that even more patients are never prescribed a home unit due to lack of physician training or frustration with meager and often inadequate reimbursements from insurance.