By Alysha Reid
An overwhelming number of patients with psoriasis are dissatisfied with their treatment plans, and undertreatment may be the culprit, according to a survey conducted by the National Psoriasis Foundation published online in JAMA Dermatology.
Researchers at the University of California, Davis, headed by principal investigator and lead author April W. Armstrong, MD, MPH, evaluated the survey results of 5,604 patients with psoriasis or psoriatic arthritis from 2003 to 2011. The patients answered questionnaires about the effectiveness of their prescription medications. Patients also self-determined the level of their psoriasis (mild, moderate, severe). Severity was not evaluated for psoriatic arthritis.
Topical medication was the sole method of treatment for a significant portion of those psoriasis patients who were treated -- even those with moderate or severe psoriasis: 29.5 percent of patients with moderate psoriasis and 21.5 percent of patients with severe psoriasis were given only topical agents to manage their condition. According to the survey, 52.3 percent of patients with psoriasis and 45.5 percent of psoriatic arthritis patients don't think they are living well with their conditions.
Psoriasis is an autoimmune disorder that occurs when the body's immune system attacks the skin cells. Depending on the type of psoriasis, scaly patches, spots, bumps, plaques, or rashes can form on the skin. Psoriasis flares can vary in severity - some flares may only appear in isolated areas of the body, such as the elbows and ears, while more severe forms can cover the entire body. In some cases, the flares may range from being painless to being itchy or painful.
Doctors prescribe treatment regimens depending on the severity of psoriasis. For less severe cases, topical treatments such as creams or shampoos may be enough. For moderate cases, doctors may prescribe ultraviolet lights or lasers. Oral systemic medications such as methotrexate is another treatment option, but in the most severe cases, injectable biologics that suppress the immune system such as Embrel and Humira are prescribed.
But more data from the survey suggests that undertreatment for psoriasis isn't the only concern: Nearly half (49.2 percent) of the patients surveyed with mild psoriasis, over a third (35.5 percent) with moderate psoriasis, and nearly a third (29.7 percent) with severe psoriasis said they had no treatment.
Doctor-Patient Relationship: Key Factor in Psoriasis Treatment
"Some people want aggressive treatment and others don't," said Dr. Colby Evans, a certified dermatologist and owner of Evans Dermatology Partners in Austin, Tex. In his practice, Dr. Evans prescribes all levels of medication, but focuses on using the minimal level of treatment necessary since stronger psoriasis treatment methods have more profound side effects, including a weaker immune system and anemia.
And according to the survey, the side effects of stronger medications are a concern. More than eighteen percent of psoriasis patients who receive only topical medications say they do it to avoid adverse effects. And sixteen percent of patients who only use topical medications don't consider their psoriasis serious enough to try other treatments.
When evaluating the study results, Dr. Armstrong said she was alarmed at the numbers of patients with moderate to severe psoriasis who were only taking topical agents, since a combination therapy using multiple methods is usually the best. "These people really need good treatments to keep their psoriasis under control," she said.
Decisions by doctors also explained why some patients only received topical treatment. Armstrong noticed that many patients only received topical medication prescriptions from their doctors. In the survey, more than 14 percent of patients cited "doctor will not prescribe any other treatments" as a reason why they relied only on topical agents.
Dr. Evans says that treatment regimens can depend on the type of doctor the patient visits. Since psoriasis manifests itself on the skin, some patients may rely only on family doctors. Even doctors who specialize in dermatology may have limited experience with psoriasis. For example, some dermatologists focus on other areas, such as cosmetic surgery.
"Different doctors have very different experiences with psoriasis," he said. "Finding the right doctor is critical."
But even doctors with experience treating psoriasis may not be familiar with the constantly-evolving landscape of psoriasis treatment, according to Adam Friedman, MD, director of dermatologic research and associate residency program director at the unified division of dermatology of Montefiore Medical Center. Many advances and improvements have been made, but current rules designed to prevent conflicts of interests between physicians and companies mean that doctors may not know enough about the medication to prescribe it comfortably.
"Many, if not most, of resident programs have restrictions to access to pharmaceutical companies and marketing," Dr. Friedman said.
Money Matters and Psoriasis
The financial costs of treating psoriasis may also be a reason why other methods aren't used. Topical medications tend to cost less, and was another reason why patients in the survey didn't use other methods of psoriasis treatment. According to Evans, stronger psoriasis treatment methods can cost upwards of $25,000 a year.
"Some patients are not able to access the best treatment because of cost," he said. "A high deductible, high copay, or having no insurance can prevent them from getting the right care. Armstrong agreed that high expense often prevented better management of psoriasis.
"A doctor might try to prescribe more effective treatment, but it can be denied by insurance companies," she said.
According to Friedman, it can difficult for doctors to prescribe stronger psoriasis medications, such as biologics and systemic medications because of a time-consuming process called prior authorization. With prior authorization, doctors need to submit additional paperwork and patient records to prove that the medication is needed. "We have assigned an individual to do prior authorizations, but some smaller private practices may not have the resources," he said.
"All of these great new drugs are coming out, and patients can't get them."
Knowledge is Power for Psoriasis
Both Evans and Armstrong agreed that education is critical to a better psoriasis patient experience. And while some in the medical community already know that psoriasis patients are dissatisfied, Evans believes this study proves just how serious the problem is. "It helps us know that the message is not getting out," he said. "It quantifies it."
Armstrong is confident that her study will help organizations such as the National Psoriasis Foundation educate and empower doctors to make better decisions for their patients. "We would like to perform more awareness efforts," she said. But those efforts won't just occur in the doctor's office.
"I hope that the results will serve as a foundation or impetus for payers to make available all treatments for psoriasis," Armstrong said. "We would like payers to work on allowing adequate insurance coverage."
Friedman said that while topical medications may be appropriate for milder forms of psoriasis, patient access to stronger psoriasis medications when needed may help them prevent more serious health complications down the line. He pointed out numerous studies that suggest how harmful psoriasis inflammation may be - and how it can affect the overall health of the patient. "That inflammation is affecting other organ systems. [It can increase] the risk of high blood pressure, erectile dysfunction, and diabetes," he said. "Psoriasis is not skin deep."
"Many Psoriasis Patients Are Undertreated, Says Study" originally appeared on Everyday Health.