Therapies for Psoriasis: Clinical and Economic Comparisons

November 2020 | Volume 19 | Issue 11 | Original Article | 1101 | Copyright © November 2020


Published online November 1, 2020

Albert Marchetti MDa, Tina Bhutani MDb, Benjamin Lockshin MDc, Daniel M. Siegel MDd, Frederick Behringer MDe

aMed-ERA, Inc., New York, NY; Rutgers New Jersey Medical School, Newark, NJ
BPsoriasis & Skin Treatment Center; Dermatology Clinical Research Unit, University of California, San Francisco, CA
cClinical Trials Center; Derm Associates, Silver Spring, MD
dSUNY Downstate and Brooklyn Veterans Administration, New York, NY
eSuncoast Skin Solutions, Ocala, FL

Abstract
Background: Clinical and economic comparisons of therapies for plaque psoriasis are regularly updated following each new devel- opment in the field. With the recent availability of a novel accessory (Multi Micro DoseTM [MMD®] tip) for the 308nm excimer laser (XTRAC®, Strata Skin Sciences, Horsham, PA), which can determine and deliver an optimal therapeutic dose (OTDTM) of ultraviolet-B light in an improved protocol, the need for comparative health-economic assessment recurs. To this end, a comprehensive evaluation of treatment-related costs was undertaken from the payer perspective. Results show that outcomes are influenced by many factors; most importantly, the severity and extent of disease, treatment selection, and patient preference, as well as compliance, adherence, and persistence with care. Among study comparators, the 308nm excimer laser – XTRAC – with its latest MMD enhancement, is safe and delivers incremental clinical benefits with the potential for significant cost savings. These benefits are particularly relevant today in the context of SARS-CoV-2 virus and the COVid-19 pandemic.

J Drugs Dermatol. 2020;19(11):1101-1108. doi:10.36849/JDD.2020.5510

BACKGROUND

Plaque psoriasis is an immune-mediated chronic inflammatory disease that is physically categorized by raised scaly epidermal plaques. Pathophysiology is yet to be fully elucidated but is described as keratinocyte and vascular hyperplasia with an infiltrate of T-lymphocytes, neutrophils, and various other inflammatory cells into affected regions of epidermis.1 Immune dysfunction involving the release of cytokines from infiltrated T cells, dendritic cells, resident immune cells and hyperplastic keratinocytes drives pathologic mechanisms.2

Approximately 2.2% of Americans has psoriasis.3 Worldwide, more than 125 million people suffer from the physical and psychologic impact of the disorder.4

Millions of psoriasis-related healthcare visits occur annually in the US.5 Estimated direct medical costs before broad utilization of biologic therapies averaged from hundreds to thousands of dollars/patient/year and were correctly predicted to rise with the expanded use of biologic therapies.6-8 In 2013 dollars, the total annual healthcare costs related to psoriasis in the U.S. amounted to $112–$135 billion, according to previous economic analyses and assessments from the National Psoriasis Foundation.9

Therapy
With treatment, providers seek to reduce the signs and symptoms of disease as measured by reductions in the psoriasis area and severity index (PASI) and/or physician global assessment (PGA) score.10 Therapeutic selection is dictated initially by severity, extent of disease, and impact on quality of life.11 Thereafter, the frequency and severity of potential adverse events as well as the likelihood of response, speed of onset, duration of remission, need for maintenance, and affordability of care drive therapeutic decisions. Patient preference must also be considered.12,13 Finally, providers prefer therapies that are safe, effective, and easy to administer, while payers prefer less costly options. Note: with the advent of COVid-19, some safety concerns have been re-emphasized.

The American Academy of Dermatology treatment guidelines recommend that therapy for mild-to-moderate disease begins with topical corticosteroids, plus/minus other topicals such as calcipotriene or tazarotene, alone or in combination.14 For more severe, extensive, or recalcitrant disease, phototherapies, oral systemics, or biologics are indicated in this order and may be used solo or in combination with each other and/or topicals.14 

The real-life utilization of all interventions is variable, as they may be switched, discontinued, restarted, combined, rotated,