Despite advancements in therapies for psoriasis, a large proportion of patients are not treated or are receiving suboptimal treatment, according to analysis of a series of comprehensive patient surveys.
The analysis showed that nearly half of the patients with mild psoriasis were receiving no treatments at all in 2011, while 42% of them were treated only with topical agents. In other words, they were undertreated.
On a positive note, the proportion of patients with severe psoriasis who reported receiving no treatment dropped from 30% in the early 2000s to 9% in 2011. Still, 22% of them were undertreated and were prescribed topical medications alone (JAMA Dermatol. 2013 Aug. 14 [doi: 10.1001/jamadermatol.2013.5264]).
The study also revealed that many of the patients were dissatisfied with their treatment, highlighting "a call to action for [dermatologists] to actively seek feedback from psoriasis patients, and find out how their condition is being treated from their perspective," said Dr. April W. Armstrong, lead author of the study and associate professor of dermatology at the University of California, Davis.
"And since many new medications are coming up as well, we should be up to date on the data and literature, and be comfortable with using all sorts of different treatment modalities so that we can offer patients a wide range of treatment options and be able to individualize the treatments," Dr. Armstrong said in an interview.
Meanwhile, the type of health insurance can limit treatment options. In two of the surveys, patients were asked why they discontinued using biological agents. Lack of health insurance was among the top reasons.
"Hopefully, payers will pay attention and find a way to work with providers to make therapies more accessible," Dr. Armstrong said. "Many of our patients need systemic treatments, and I hope payers will pay attention and understand consequences."
Some estimates show that the cost of psoriasis is nearly $11 billion in the United States. But there’s a dearth of studies on patients’ perspectives and the extent to which patients are treated, the authors noted.
One source that has captured such data is the National Psoriasis Foundation’s (NPF’s) biannual surveys of its members. A 2007 study of the survey data was the first to show that as many as 40% of patients with moderate to severe psoriasis didn’t receive treatment (J. Am. Acad. Dermatol. 2007;57:957-62).
For their analysis, Dr. Armstrong and her colleagues examined 13 NPF surveys conducted during 2003-2011. More than 5,600 patients with psoriasis and/or psoriatic arthritis completed the surveys. They had a mean age of 50 years, and most were white.
The analysis showed that the proportion of patients with mild psoriasis who didn’t receive any treatment rose from 42% in the 2003-2005 period to 49% in 2011. The percentage of untreated patients with moderate psoriasis dropped from 36% to 24% during that period, and from 30% to 9% for patients with severe psoriasis.
Dr. Armstrong said there are several explanations for why patients go untreated. Psoriasis is chronic, and after going to one, two, or three doctors and not getting satisfactory results, the patients may give up, she said. "Some of the untreated patients might have sought help before and decided that nothing could be done, and resolved [themselves] to their situation."
Meanwhile, she expressed her concern with the proportion of patients who were undertreated. Close to 30% of patients with moderate psoriasis and 22% of those with severe psoriasis were treated only with topical agents, and the proportions were higher in 2011 than in the 2003-2005 period.
Patients said the top three reasons they used topical agents alone were because they had fewer adverse effects than other treatments, their disease wasn’t serious enough for other kinds of treatments, and their physician wouldn’t prescribe any other treatments.
Dr. April W. Armstrong
"There is still much to be learned about exactly why psoriasis patients are undertreated," Dr. Junko Takeshita of the University of Pennsylvania said via e-mail.
But, "it is essential that patients be properly educated about the risks and benefits of various therapies so that they can make informed treatment choices. It is also important for physicians to be aware of and inform their psoriasis patients about the overall health implications of psoriasis itself (i.e., associations with cardiovascular and metabolic diseases as well as emerging associations with other comorbid diseases)," said Dr. Takeshita, who was not involved in the study.
The study also showed the most common forms of various treatment modalities, with ultraviolet B as the most common form of phototherapy, methotrexate as the top oral agent, and etanercept and adalimumab as the most common biological agents.