Psoriasis

Psoriasis is one of the most common systemic inflammatory diseases and affects the quality of life of the affected persons profoundly. Further knowledge of the pathogenesis and new biotechnological techniques have made it possible to develop new targeted therapies, such as antibodies against tumor necrosis factor (TNF)-alpha. Today, 3 TNF inhibitors, infliximab, adalimumab, and Etanercept, have been approved for the treatment of psoriasis arthritis, psoriasis, and other indications like Crohn’s disease, depending on the distinct substance by the European Medicines Agency. Golimumab was approved in September 2009 for the use in psoriasis arthritis, respectively. These substances have added new effective treatment options to the therapeutic armamentarium of psoriasis. To use these new treatments for the best of our patients, it is important to know the correct application, the advantages, as well as contraindications or possible adverse effects of the substances. This article provides an update on the TNF-alpha inhibitors with emphasis on practical daily use. Most data are on the basis of high-quality studies and official guidelines, but if necessary, data from recent publications or clinical expertise have been added. In summary, with TNF inhibitors we have gained effective new treatment options showing a favorable safety profile when paying attention to safety aspects before and during therapy (screening, monitoring).

*For a PDF of the full article, click on the link to the left of this introduction.

Psoriasis is one of the most common systemic inflammatory diseases and affects the quality of life of the affected persons profoundly. Further knowledge of the pathogenesis and new biotechnological techniques have made it possible to develop new targeted therapies, such as antibodies against tumor necrosis factor (TNF)-alpha. Today, 3 TNF inhibitors, infliximab, adalimumab, and Etanercept, have been approved for the treatment of psoriasis arthritis, psoriasis, and other indications like Crohn’s disease, depending on the distinct substance by the European Medicines Agency. Golimumab was approved in September 2009 for the use in psoriasis arthritis, respectively. These substances have added new effective treatment options to the therapeutic armamentarium of psoriasis. To use these new treatments for the best of our patients, it is important to know the correct application, the advantages, as well as contraindications or possible adverse effects of the substances. This article provides an update on the TNF-alpha inhibitors with emphasis on practical daily use. Most data are on the basis of high-quality studies and official guidelines, but if necessary, data from recent publications or clinical expertise have been added. In summary, with TNF inhibitors we have gained effective new treatment options showing a favorable safety profile when paying attention to safety aspects before and during therapy (screening, monitoring).

*For a PDF of the full article, click on the link to the left of this introduction.

Psoriasis is one of the most common systemic inflammatory diseases and affects the quality of life of the affected persons profoundly. Further knowledge of the pathogenesis and new biotechnological techniques have made it possible to develop new targeted therapies, such as antibodies against tumor necrosis factor (TNF)-alpha. Today, 3 TNF inhibitors, infliximab, adalimumab, and Etanercept, have been approved for the treatment of psoriasis arthritis, psoriasis, and other indications like Crohn’s disease, depending on the distinct substance by the European Medicines Agency. Golimumab was approved in September 2009 for the use in psoriasis arthritis, respectively. These substances have added new effective treatment options to the therapeutic armamentarium of psoriasis. To use these new treatments for the best of our patients, it is important to know the correct application, the advantages, as well as contraindications or possible adverse effects of the substances. This article provides an update on the TNF-alpha inhibitors with emphasis on practical daily use. Most data are on the basis of high-quality studies and official guidelines, but if necessary, data from recent publications or clinical expertise have been added. In summary, with TNF inhibitors we have gained effective new treatment options showing a favorable safety profile when paying attention to safety aspects before and during therapy (screening, monitoring).

*For a PDF of the full article, click on the link to the left of this introduction.

The choice of therapeutic agents for patients with moderate-to-severe psoriasis has expanded significantly in the past decade. With new understanding of the immunologic basis of psoriasis, multiple new potential targets for therapy have been identified. It is likely that a series of new medications to focus on the newly identified pathways is on the horizon. The first pathway targeted by new medications focuses on the p40 subunit that is shared by interleukin (IL)-12 and IL-23. Two human anti-p40 antibodies have been used therapeutically in psoriasis to date, ustekinumab (CNTO-1275, Stelara, Centocor, Horsham, PA) and briakinumab (ABT-874, Abbott, Abbott Park, IL). Ustekinumab was recently approved by the United States Food and Drug Administration, making it the first medication approved in the United States to work by this pathway while briakinumab is currently in phase III clinical trials. 

*For a PDF of the full article, click on the link to the left of this introduction.

The choice of therapeutic agents for patients with moderate-to-severe psoriasis has expanded significantly in the past decade. With new understanding of the immunologic basis of psoriasis, multiple new potential targets for therapy have been identified. It is likely that a series of new medications to focus on the newly identified pathways is on the horizon. The first pathway targeted by new medications focuses on the p40 subunit that is shared by interleukin (IL)-12 and IL-23. Two human anti-p40 antibodies have been used therapeutically in psoriasis to date, ustekinumab (CNTO-1275, Stelara, Centocor, Horsham, PA) and briakinumab (ABT-874, Abbott, Abbott Park, IL). Ustekinumab was recently approved by the United States Food and Drug Administration, making it the first medication approved in the United States to work by this pathway while briakinumab is currently in phase III clinical trials. 

*For a PDF of the full article, click on the link to the left of this introduction.

The choice of therapeutic agents for patients with moderate-to-severe psoriasis has expanded significantly in the past decade. With new understanding of the immunologic basis of psoriasis, multiple new potential targets for therapy have been identified. It is likely that a series of new medications to focus on the newly identified pathways is on the horizon. The first pathway targeted by new medications focuses on the p40 subunit that is shared by interleukin (IL)-12 and IL-23. Two human anti-p40 antibodies have been used therapeutically in psoriasis to date, ustekinumab (CNTO-1275, Stelara, Centocor, Horsham, PA) and briakinumab (ABT-874, Abbott, Abbott Park, IL). Ustekinumab was recently approved by the United States Food and Drug Administration, making it the first medication approved in the United States to work by this pathway while briakinumab is currently in phase III clinical trials. 

*For a PDF of the full article, click on the link to the left of this introduction.

Alefacept was the first biological agent approved by the Food and Drug Administration for the treatment of psoriasis. Alefacept was initially approved as an intravenous and intramuscular medication. It is available only as an intramuscular medication. Alefacept is an immunosuppressive dimeric fusion protein that consists of the extracellular CD2-binding portion of the human leukocyte function antigen-3 linked to the Fc (hinge, CH2, CH3 domains) portion of human immunoglobulin G. Alefacept selectively blocks the leukocyte function antigen-3:CD2 costimulatory pathway, which is important in the reactivation of memory effector T cells. Alefacept also reduces the number of memory effector T cells in the blood and in the skin.

*For a PDF of the full article, click on the link to the left of this introduction.

Alefacept was the first biological agent approved by the Food and Drug Administration for the treatment of psoriasis. Alefacept was initially approved as an intravenous and intramuscular medication. It is available only as an intramuscular medication. Alefacept is an immunosuppressive dimeric fusion protein that consists of the extracellular CD2-binding portion of the human leukocyte function antigen-3 linked to the Fc (hinge, CH2, CH3 domains) portion of human immunoglobulin G. Alefacept selectively blocks the leukocyte function antigen-3:CD2 costimulatory pathway, which is important in the reactivation of memory effector T cells. Alefacept also reduces the number of memory effector T cells in the blood and in the skin.

*For a PDF of the full article, click on the link to the left of this introduction.

Alefacept was the first biological agent approved by the Food and Drug Administration for the treatment of psoriasis. Alefacept was initially approved as an intravenous and intramuscular medication. It is available only as an intramuscular medication. Alefacept is an immunosuppressive dimeric fusion protein that consists of the extracellular CD2-binding portion of the human leukocyte function antigen-3 linked to the Fc (hinge, CH2, CH3 domains) portion of human immunoglobulin G. Alefacept selectively blocks the leukocyte function antigen-3:CD2 costimulatory pathway, which is important in the reactivation of memory effector T cells. Alefacept also reduces the number of memory effector T cells in the blood and in the skin.

*For a PDF of the full article, click on the link to the left of this introduction.

Psoriatic arthritis (PsA) is an inflammatory arthritis that occurs in individuals with psoriasis. The primary goals in the treatment of PsA are reduction of pain; improvement in the other signs and symptoms of disease, including skin and nail involvement; optimization of functional capacity and quality of life; and inhibition of the progression of joint damage. These goals should be achieved while minimizing potential toxicities from treatment. The management of PsA should simultaneously target arthritis, skin disease, and other manifestations of PsA, including involvement of the axial skeleton, dactylitis, enthesitis, and eye inflammation. In this respect targeted biological agents, primarily tumor necrosis factor inhibitors, have emerged as generally well tolerated and highly effective alternatives to traditional disease modifying antirheumatic drugs. Herein we review the evidence regarding the treatment of PsA arthritis with biological agents.

*For a PDF of the full article, click on the link to the left of this introduction.

Psoriatic arthritis (PsA) is an inflammatory arthritis that occurs in individuals with psoriasis. The primary goals in the treatment of PsA are reduction of pain; improvement in the other signs and symptoms of disease, including skin and nail involvement; optimization of functional capacity and quality of life; and inhibition of the progression of joint damage. These goals should be achieved while minimizing potential toxicities from treatment. The management of PsA should simultaneously target arthritis, skin disease, and other manifestations of PsA, including involvement of the axial skeleton, dactylitis, enthesitis, and eye inflammation. In this respect targeted biological agents, primarily tumor necrosis factor inhibitors, have emerged as generally well tolerated and highly effective alternatives to traditional disease modifying antirheumatic drugs. Herein we review the evidence regarding the treatment of PsA arthritis with biological agents.

*For a PDF of the full article, click on the link to the left of this introduction.

Psoriatic arthritis (PsA) is an inflammatory arthritis that occurs in individuals with psoriasis. The primary goals in the treatment of PsA are reduction of pain; improvement in the other signs and symptoms of disease, including skin and nail involvement; optimization of functional capacity and quality of life; and inhibition of the progression of joint damage. These goals should be achieved while minimizing potential toxicities from treatment. The management of PsA should simultaneously target arthritis, skin disease, and other manifestations of PsA, including involvement of the axial skeleton, dactylitis, enthesitis, and eye inflammation. In this respect targeted biological agents, primarily tumor necrosis factor inhibitors, have emerged as generally well tolerated and highly effective alternatives to traditional disease modifying antirheumatic drugs. Herein we review the evidence regarding the treatment of PsA arthritis with biological agents.

*For a PDF of the full article, click on the link to the left of this introduction.

The last decade has witnessed a significant advance in the management of refractory moderate-to-severe psoriasis. This advance is the introduction of biological therapies to clinical practice. Three classes of biological therapies have been used. Of the first 2 classes to be introduced, the T-cell inhibitors and tumor necrosis factor (TNF)-inhibitors, there have been differing fates with one of the T-cell inhibitors, efalizumab, being withdrawn because of a rare, unpredictable association with a usually fatal neurological condition, progressive multifocal leukoencephalopathy. In contrast, anti-TNF treatments are now firmly established offering a high level of efficacy and a good safety record across several indications, including psoriasis. A new approach involves targeting the p40 subunit, common to interleukins 12 and 23. Ustekinumab, the first drug in this class, now offers a viable alternative to anti-TNFs in the treatment of moderate-to-severe psoriasis. In this article, we discuss approaches that may be utilized to refine these existing therapies and examine future therapeutic targets for biological therapies.

*For a PDF of the full article, click on the link to the left of this introduction.

The last decade has witnessed a significant advance in the management of refractory moderate-to-severe psoriasis. This advance is the introduction of biological therapies to clinical practice. Three classes of biological therapies have been used. Of the first 2 classes to be introduced, the T-cell inhibitors and tumor necrosis factor (TNF)-inhibitors, there have been differing fates with one of the T-cell inhibitors, efalizumab, being withdrawn because of a rare, unpredictable association with a usually fatal neurological condition, progressive multifocal leukoencephalopathy. In contrast, anti-TNF treatments are now firmly established offering a high level of efficacy and a good safety record across several indications, including psoriasis. A new approach involves targeting the p40 subunit, common to interleukins 12 and 23. Ustekinumab, the first drug in this class, now offers a viable alternative to anti-TNFs in the treatment of moderate-to-severe psoriasis. In this article, we discuss approaches that may be utilized to refine these existing therapies and examine future therapeutic targets for biological therapies.

*For a PDF of the full article, click on the link to the left of this introduction.

The last decade has witnessed a significant advance in the management of refractory moderate-to-severe psoriasis. This advance is the introduction of biological therapies to clinical practice. Three classes of biological therapies have been used. Of the first 2 classes to be introduced, the T-cell inhibitors and tumor necrosis factor (TNF)-inhibitors, there have been differing fates with one of the T-cell inhibitors, efalizumab, being withdrawn because of a rare, unpredictable association with a usually fatal neurological condition, progressive multifocal leukoencephalopathy. In contrast, anti-TNF treatments are now firmly established offering a high level of efficacy and a good safety record across several indications, including psoriasis. A new approach involves targeting the p40 subunit, common to interleukins 12 and 23. Ustekinumab, the first drug in this class, now offers a viable alternative to anti-TNFs in the treatment of moderate-to-severe psoriasis. In this article, we discuss approaches that may be utilized to refine these existing therapies and examine future therapeutic targets for biological therapies.

*For a PDF of the full article, click on the link to the left of this introduction.

Evidence indicating the serious effects of psoriasis inflammation to the rest of the body and not just the skin, as once thought, is starting to accumulate, noted Dr. Jeffrey Sobell.

"We are just beginning to understand the impact of uncontrolled inflammation on the body, separate from the effects we're seeing in the skin and joints," Dr. Sobell, of the department of dermatology, Tufts University, Boston, said in an interview. This evidence has raised the question of whether conditions, such as cardiovascular disease (CVD), improve by "treating an individual's underlying psoriasis and controlling that tremendous inflammation" that characterizes the disease.

In addition to CVD, psoriasis patients are at an increased for depression and other conditions such as Crohn's disease, certain cancers, and chronic obstructive pulmonary disease. In a presentation at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation, Dr. Sobell focused on psoriatic arthritis (PsA), depression, and CVD.

PsA
PsA usually appears an average of 10 years after the onset of skin disease (QJ Med. 1987;62:127-41); about 70% of patients have skin manifestations initially, while 15% develop joint symptoms first, and 15% develop joint and skin symptoms simultaneously, he noted.

Dermatologists should screen for arthritis in their psoriasis patients because a prompt diagnosis is critical. Early intervention, particularly with a tumor necrosis factor (TNF) blocker, can reduce the potential for joint deformities and disability, in addition to helping alleviate the signs and symptoms of arthritis, he noted.The FDA-approved biologic treatments for PsA - etanercept, infliximab, adalimumab, and golimumab - are approved for reducing the signs and symptoms of active arthritis, including the progression of structural damage and improving physical function.

"I encourage dermatologists when seeing psoriasis patients to ask questions about arthritis symptoms," such as joint stiffness in the morning, and performing a physical examination that includes looking for asymmetric inflammatory arthritis and tender or swollen joints, said Dr. Sobell. Patients should also be asked about whether they have a family history of PsA, and, if they have joint pain, whether it fluctuates with psoriasis exacerbations, he said, noting that only about 35% of patients with PsA have simultaneous flares of skin and joints.

Depression
Depression affects about 25% of people with psoriasis, and it can be debilitating, sometimes leading to suicidal thoughts, particularly in younger patients, Dr. Sobell said. Although the disease itself has a psychological impact on patients, increased TNF levels are known to be elevated in depression. This "may be part of the pathogenesis of depression" in people with psoriasis, and therefore, TNF levels are a possible target of treatment, he said.

Evidence that treatment with an anti-TNF agent improves symptoms of depression and fatigue includes a phase III study evaluating the efficacy of etanercept, compared with placebo, in over 600 patients with moderate to severe psoriasis (Lancet 2006;367:29-35). At week 12, treatment was associated with improved symptoms of depression and fatigue. Improvements were not strongly correlated with improvements in Psoriasis Area and Severity Index scores and were also seen in patients with little improvement of psoriasis. This "may be a detectable effect of neutralization of TNF" on depression, Dr. Sobell said.

Although these results are intriguing, he added that more studies are needed to further investigate the relationship between TNF levels and depression, and that conclusions cannot be made about the impact of anti-TNF treatment and depression in the general population.

CVD
Psoriasis patients are more likely to have comorbid diseases that are CVD risk factors, such as obesity, hypertension, hyperlipidemia, and insulin resistance. However, psoriasis is also an independent risk factor for MI and CVD, which is thought to be related to the immune and inflammatory activity of skin disease, Dr. Sobell said.

He referred to evidence that TNF, which has a major role in the pathogenesis of RA and psoriasis, also plays a role in cardiovascular disease, including TNF effects on promoting insulin resistance. TNF also induces the cytokine interleukin-6, which increases C-reactive protein (CRP), an inflammatory biomarker that is associated with an increased CVD risk.

This type of evidence raises the issue of whether treatment with systemic psoriasis treatments can reduce cardiovascular risk in these patients, and whether biologic agents improve CVD risk factors and markers, Dr. Sobell said.

Most of the data that have found an association between anti-TNF therapy and improvements in CVD risk factors and markers have been in people with RA, he said. In a small study of RA patients, those treated with adalimumab had significant increases in HDL cholesterol and reduced CRP levels after 2 weeks, compared with those in the placebo group (Ann. Rheum. Dis. 2005; 64:303-5).

Evidence that systemic treatment of RA and psoriasis reduced cardiovascular events was provided in a retrospective study of over 6,000 patients with RA and over 7,000 patients with psoriasis treated between 1998 and 2003 (J.Am. Acad. Dermatol. 2005;52:262-7). The risk of CVD was significantly lower in patients treated with methotrexate in both groups, compared with those who were not (risk was reduced by 23% in those with psoriasis). The addition of folic acid further reduced the risk.

Data on the impact of anti-TNF therapies on CV events include two studies suggesting that CV events in RA patients were reduced during treatment, he said. These include a Swedish registry study of almost 1,000 RA patients, which found a significantly lower risk of cardiovascular events in those treated with an anti-TNF agent compared with controls (J. Rheum. 2005; 32: 1213-8). The impact of treatment in patients with psoriasis is unknown, he pointed out.

^{Photo courtesy Dr. Jeffrey Sobell}

Dr. Sobell disclosed that he is a speaker and consultant for Amgen, Abbott, and Centocor, and is an investigator for Abbott and Centocor. The companies are manufacturers of biologic treatments for psoriasis. SDEF and this news organization are owned by Elsevier.

Evidence indicating the serious effects of psoriasis inflammation to the rest of the body and not just the skin, as once thought, is starting to accumulate, noted Dr. Jeffrey Sobell.

"We are just beginning to understand the impact of uncontrolled inflammation on the body, separate from the effects we're seeing in the skin and joints," Dr. Sobell, of the department of dermatology, Tufts University, Boston, said in an interview. This evidence has raised the question of whether conditions, such as cardiovascular disease (CVD), improve by "treating an individual's underlying psoriasis and controlling that tremendous inflammation" that characterizes the disease.

In addition to CVD, psoriasis patients are at an increased for depression and other conditions such as Crohn's disease, certain cancers, and chronic obstructive pulmonary disease. In a presentation at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation, Dr. Sobell focused on psoriatic arthritis (PsA), depression, and CVD.

PsA
PsA usually appears an average of 10 years after the onset of skin disease (QJ Med. 1987;62:127-41); about 70% of patients have skin manifestations initially, while 15% develop joint symptoms first, and 15% develop joint and skin symptoms simultaneously, he noted.

Dermatologists should screen for arthritis in their psoriasis patients because a prompt diagnosis is critical. Early intervention, particularly with a tumor necrosis factor (TNF) blocker, can reduce the potential for joint deformities and disability, in addition to helping alleviate the signs and symptoms of arthritis, he noted.The FDA-approved biologic treatments for PsA - etanercept, infliximab, adalimumab, and golimumab - are approved for reducing the signs and symptoms of active arthritis, including the progression of structural damage and improving physical function.

"I encourage dermatologists when seeing psoriasis patients to ask questions about arthritis symptoms," such as joint stiffness in the morning, and performing a physical examination that includes looking for asymmetric inflammatory arthritis and tender or swollen joints, said Dr. Sobell. Patients should also be asked about whether they have a family history of PsA, and, if they have joint pain, whether it fluctuates with psoriasis exacerbations, he said, noting that only about 35% of patients with PsA have simultaneous flares of skin and joints.

Depression
Depression affects about 25% of people with psoriasis, and it can be debilitating, sometimes leading to suicidal thoughts, particularly in younger patients, Dr. Sobell said. Although the disease itself has a psychological impact on patients, increased TNF levels are known to be elevated in depression. This "may be part of the pathogenesis of depression" in people with psoriasis, and therefore, TNF levels are a possible target of treatment, he said.

Evidence that treatment with an anti-TNF agent improves symptoms of depression and fatigue includes a phase III study evaluating the efficacy of etanercept, compared with placebo, in over 600 patients with moderate to severe psoriasis (Lancet 2006;367:29-35). At week 12, treatment was associated with improved symptoms of depression and fatigue. Improvements were not strongly correlated with improvements in Psoriasis Area and Severity Index scores and were also seen in patients with little improvement of psoriasis. This "may be a detectable effect of neutralization of TNF" on depression, Dr. Sobell said.

Although these results are intriguing, he added that more studies are needed to further investigate the relationship between TNF levels and depression, and that conclusions cannot be made about the impact of anti-TNF treatment and depression in the general population.

CVD
Psoriasis patients are more likely to have comorbid diseases that are CVD risk factors, such as obesity, hypertension, hyperlipidemia, and insulin resistance. However, psoriasis is also an independent risk factor for MI and CVD, which is thought to be related to the immune and inflammatory activity of skin disease, Dr. Sobell said.

He referred to evidence that TNF, which has a major role in the pathogenesis of RA and psoriasis, also plays a role in cardiovascular disease, including TNF effects on promoting insulin resistance. TNF also induces the cytokine interleukin-6, which increases C-reactive protein (CRP), an inflammatory biomarker that is associated with an increased CVD risk.

This type of evidence raises the issue of whether treatment with systemic psoriasis treatments can reduce cardiovascular risk in these patients, and whether biologic agents improve CVD risk factors and markers, Dr. Sobell said.

Most of the data that have found an association between anti-TNF therapy and improvements in CVD risk factors and markers have been in people with RA, he said. In a small study of RA patients, those treated with adalimumab had significant increases in HDL cholesterol and reduced CRP levels after 2 weeks, compared with those in the placebo group (Ann. Rheum. Dis. 2005; 64:303-5).

Evidence that systemic treatment of RA and psoriasis reduced cardiovascular events was provided in a retrospective study of over 6,000 patients with RA and over 7,000 patients with psoriasis treated between 1998 and 2003 (J.Am. Acad. Dermatol. 2005;52:262-7). The risk of CVD was significantly lower in patients treated with methotrexate in both groups, compared with those who were not (risk was reduced by 23% in those with psoriasis). The addition of folic acid further reduced the risk.

Data on the impact of anti-TNF therapies on CV events include two studies suggesting that CV events in RA patients were reduced during treatment, he said. These include a Swedish registry study of almost 1,000 RA patients, which found a significantly lower risk of cardiovascular events in those treated with an anti-TNF agent compared with controls (J. Rheum. 2005; 32: 1213-8). The impact of treatment in patients with psoriasis is unknown, he pointed out.

^{Photo courtesy Dr. Jeffrey Sobell}

Dr. Sobell disclosed that he is a speaker and consultant for Amgen, Abbott, and Centocor, and is an investigator for Abbott and Centocor. The companies are manufacturers of biologic treatments for psoriasis. SDEF and this news organization are owned by Elsevier.

Evidence indicating the serious effects of psoriasis inflammation to the rest of the body and not just the skin, as once thought, is starting to accumulate, noted Dr. Jeffrey Sobell.

"We are just beginning to understand the impact of uncontrolled inflammation on the body, separate from the effects we're seeing in the skin and joints," Dr. Sobell, of the department of dermatology, Tufts University, Boston, said in an interview. This evidence has raised the question of whether conditions, such as cardiovascular disease (CVD), improve by "treating an individual's underlying psoriasis and controlling that tremendous inflammation" that characterizes the disease.

In addition to CVD, psoriasis patients are at an increased for depression and other conditions such as Crohn's disease, certain cancers, and chronic obstructive pulmonary disease. In a presentation at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation, Dr. Sobell focused on psoriatic arthritis (PsA), depression, and CVD.

PsA
PsA usually appears an average of 10 years after the onset of skin disease (QJ Med. 1987;62:127-41); about 70% of patients have skin manifestations initially, while 15% develop joint symptoms first, and 15% develop joint and skin symptoms simultaneously, he noted.

Dermatologists should screen for arthritis in their psoriasis patients because a prompt diagnosis is critical. Early intervention, particularly with a tumor necrosis factor (TNF) blocker, can reduce the potential for joint deformities and disability, in addition to helping alleviate the signs and symptoms of arthritis, he noted.The FDA-approved biologic treatments for PsA - etanercept, infliximab, adalimumab, and golimumab - are approved for reducing the signs and symptoms of active arthritis, including the progression of structural damage and improving physical function.

"I encourage dermatologists when seeing psoriasis patients to ask questions about arthritis symptoms," such as joint stiffness in the morning, and performing a physical examination that includes looking for asymmetric inflammatory arthritis and tender or swollen joints, said Dr. Sobell. Patients should also be asked about whether they have a family history of PsA, and, if they have joint pain, whether it fluctuates with psoriasis exacerbations, he said, noting that only about 35% of patients with PsA have simultaneous flares of skin and joints.

Depression
Depression affects about 25% of people with psoriasis, and it can be debilitating, sometimes leading to suicidal thoughts, particularly in younger patients, Dr. Sobell said. Although the disease itself has a psychological impact on patients, increased TNF levels are known to be elevated in depression. This "may be part of the pathogenesis of depression" in people with psoriasis, and therefore, TNF levels are a possible target of treatment, he said.

Evidence that treatment with an anti-TNF agent improves symptoms of depression and fatigue includes a phase III study evaluating the efficacy of etanercept, compared with placebo, in over 600 patients with moderate to severe psoriasis (Lancet 2006;367:29-35). At week 12, treatment was associated with improved symptoms of depression and fatigue. Improvements were not strongly correlated with improvements in Psoriasis Area and Severity Index scores and were also seen in patients with little improvement of psoriasis. This "may be a detectable effect of neutralization of TNF" on depression, Dr. Sobell said.

Although these results are intriguing, he added that more studies are needed to further investigate the relationship between TNF levels and depression, and that conclusions cannot be made about the impact of anti-TNF treatment and depression in the general population.

CVD
Psoriasis patients are more likely to have comorbid diseases that are CVD risk factors, such as obesity, hypertension, hyperlipidemia, and insulin resistance. However, psoriasis is also an independent risk factor for MI and CVD, which is thought to be related to the immune and inflammatory activity of skin disease, Dr. Sobell said.

He referred to evidence that TNF, which has a major role in the pathogenesis of RA and psoriasis, also plays a role in cardiovascular disease, including TNF effects on promoting insulin resistance. TNF also induces the cytokine interleukin-6, which increases C-reactive protein (CRP), an inflammatory biomarker that is associated with an increased CVD risk.

This type of evidence raises the issue of whether treatment with systemic psoriasis treatments can reduce cardiovascular risk in these patients, and whether biologic agents improve CVD risk factors and markers, Dr. Sobell said.

Most of the data that have found an association between anti-TNF therapy and improvements in CVD risk factors and markers have been in people with RA, he said. In a small study of RA patients, those treated with adalimumab had significant increases in HDL cholesterol and reduced CRP levels after 2 weeks, compared with those in the placebo group (Ann. Rheum. Dis. 2005; 64:303-5).

Evidence that systemic treatment of RA and psoriasis reduced cardiovascular events was provided in a retrospective study of over 6,000 patients with RA and over 7,000 patients with psoriasis treated between 1998 and 2003 (J.Am. Acad. Dermatol. 2005;52:262-7). The risk of CVD was significantly lower in patients treated with methotrexate in both groups, compared with those who were not (risk was reduced by 23% in those with psoriasis). The addition of folic acid further reduced the risk.

Data on the impact of anti-TNF therapies on CV events include two studies suggesting that CV events in RA patients were reduced during treatment, he said. These include a Swedish registry study of almost 1,000 RA patients, which found a significantly lower risk of cardiovascular events in those treated with an anti-TNF agent compared with controls (J. Rheum. 2005; 32: 1213-8). The impact of treatment in patients with psoriasis is unknown, he pointed out.

^{Photo courtesy Dr. Jeffrey Sobell}

Dr. Sobell disclosed that he is a speaker and consultant for Amgen, Abbott, and Centocor, and is an investigator for Abbott and Centocor. The companies are manufacturers of biologic treatments for psoriasis. SDEF and this news organization are owned by Elsevier.

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Many patients taking adalimumab for psoriasis over the long term can expect a high rate of response that persists, but there is some real but small loss of effect, Dr. Kenneth B. Gordon said at a dermatology seminar sponsored by Skin Disease Education Foundation.

Adalimumab (Humira) is approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylosis, and Crohn's disease. The best published long-term data for adalimumab in psoriasis is from the double-blind, placebo-controlled REVEAL trial, which evaluated the PASI 75 response rates between weeks 4 and 24 of treatment in 1,212 patients (J. Am. Acad. Dermatol. 2008;58:106-15). Data from the trial showed that the PASI 75 response rates among patients on adalimumab were 19% at week 4, 54% at week 8, 68% at week 12, 71% at week 16, and 70% at week 24.

A second component of the trial evaluated the sustained responsiveness from weeks 16-33 in adalimumab-treated patients. The researchers found that the mean percentage of PASI improvement in this cohort was 92% at week 16, 92% at week 24, and 89% at week 33.

The great majority, but not all, of patients on adalimumab maintain responses, said Dr. Gordon, who heads the division of dermatology at NorthShore University HealthSystem, Evanston, Ill. "We do lose patients with treatment over time."

A cohort of 233 patients from the trial who received continuous adalimumab therapy up to 100 weeks showed that 100% of patients achieved a PASI 75 at week 33. But the percentage who sustained a PASI 75 dropped over time, from 85% at week 52 to 87% at week 76, and 83% at week 100.

"This tells me that of the patients who are doing well after about 8 months, the great majority are going to maintain response, but there are going to be a few that lose," he said. "It's the patients that are having marginal responses that you lose."

As for safety, the side effect profile seems to be relatively consistent with adalimumab. "It does not seem to increase over time," he emphasized. Data from the REVEAL trial found that the rate of serious adverse events was similar to the placebo group, about 1.8%.

According to pooled data from integrated studies, the top five most common adverse reactions are nasopharyngitis, followed by upper respiratory infection, headache, arthralgia, and injection site reaction.

If loss of efficacy with long-term use of adalimumab occurs in patients with psoriasis, it tends to happen in the first year.

"We think about treatment for psoriasis in 12- or 16-week blocks because that's what the primary end points of the clinical trials are," he said. "But psoriasis is a long-term disease. People have it for 20, 30, or 40 years, so we need to think beyond the realm of short-term."

Dr. Gordon disclosed that he has received research support or honoraria from Abbott, which manufactures adalimumab as Humira, as well as Amgen, Astellas, Centocor, and Genentech.

LAS VEGAS – Many patients taking adalimumab for psoriasis over the long term can expect a high rate of response that persists, but there is some real but small loss of effect, Dr. Kenneth B. Gordon said at a dermatology seminar sponsored by Skin Disease Education Foundation.

Adalimumab (Humira) is approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylosis, and Crohn's disease. The best published long-term data for adalimumab in psoriasis is from the double-blind, placebo-controlled REVEAL trial, which evaluated the PASI 75 response rates between weeks 4 and 24 of treatment in 1,212 patients (J. Am. Acad. Dermatol. 2008;58:106-15). Data from the trial showed that the PASI 75 response rates among patients on adalimumab were 19% at week 4, 54% at week 8, 68% at week 12, 71% at week 16, and 70% at week 24.

A second component of the trial evaluated the sustained responsiveness from weeks 16-33 in adalimumab-treated patients. The researchers found that the mean percentage of PASI improvement in this cohort was 92% at week 16, 92% at week 24, and 89% at week 33.

The great majority, but not all, of patients on adalimumab maintain responses, said Dr. Gordon, who heads the division of dermatology at NorthShore University HealthSystem, Evanston, Ill. "We do lose patients with treatment over time."

A cohort of 233 patients from the trial who received continuous adalimumab therapy up to 100 weeks showed that 100% of patients achieved a PASI 75 at week 33. But the percentage who sustained a PASI 75 dropped over time, from 85% at week 52 to 87% at week 76, and 83% at week 100.

"This tells me that of the patients who are doing well after about 8 months, the great majority are going to maintain response, but there are going to be a few that lose," he said. "It's the patients that are having marginal responses that you lose."

As for safety, the side effect profile seems to be relatively consistent with adalimumab. "It does not seem to increase over time," he emphasized. Data from the REVEAL trial found that the rate of serious adverse events was similar to the placebo group, about 1.8%.

According to pooled data from integrated studies, the top five most common adverse reactions are nasopharyngitis, followed by upper respiratory infection, headache, arthralgia, and injection site reaction.

If loss of efficacy with long-term use of adalimumab occurs in patients with psoriasis, it tends to happen in the first year.

"We think about treatment for psoriasis in 12- or 16-week blocks because that's what the primary end points of the clinical trials are," he said. "But psoriasis is a long-term disease. People have it for 20, 30, or 40 years, so we need to think beyond the realm of short-term."

Dr. Gordon disclosed that he has received research support or honoraria from Abbott, which manufactures adalimumab as Humira, as well as Amgen, Astellas, Centocor, and Genentech.

LAS VEGAS – Many patients taking adalimumab for psoriasis over the long term can expect a high rate of response that persists, but there is some real but small loss of effect, Dr. Kenneth B. Gordon said at a dermatology seminar sponsored by Skin Disease Education Foundation.

Adalimumab (Humira) is approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylosis, and Crohn's disease. The best published long-term data for adalimumab in psoriasis is from the double-blind, placebo-controlled REVEAL trial, which evaluated the PASI 75 response rates between weeks 4 and 24 of treatment in 1,212 patients (J. Am. Acad. Dermatol. 2008;58:106-15). Data from the trial showed that the PASI 75 response rates among patients on adalimumab were 19% at week 4, 54% at week 8, 68% at week 12, 71% at week 16, and 70% at week 24.

A second component of the trial evaluated the sustained responsiveness from weeks 16-33 in adalimumab-treated patients. The researchers found that the mean percentage of PASI improvement in this cohort was 92% at week 16, 92% at week 24, and 89% at week 33.

The great majority, but not all, of patients on adalimumab maintain responses, said Dr. Gordon, who heads the division of dermatology at NorthShore University HealthSystem, Evanston, Ill. "We do lose patients with treatment over time."

A cohort of 233 patients from the trial who received continuous adalimumab therapy up to 100 weeks showed that 100% of patients achieved a PASI 75 at week 33. But the percentage who sustained a PASI 75 dropped over time, from 85% at week 52 to 87% at week 76, and 83% at week 100.

"This tells me that of the patients who are doing well after about 8 months, the great majority are going to maintain response, but there are going to be a few that lose," he said. "It's the patients that are having marginal responses that you lose."

As for safety, the side effect profile seems to be relatively consistent with adalimumab. "It does not seem to increase over time," he emphasized. Data from the REVEAL trial found that the rate of serious adverse events was similar to the placebo group, about 1.8%.

According to pooled data from integrated studies, the top five most common adverse reactions are nasopharyngitis, followed by upper respiratory infection, headache, arthralgia, and injection site reaction.

If loss of efficacy with long-term use of adalimumab occurs in patients with psoriasis, it tends to happen in the first year.

"We think about treatment for psoriasis in 12- or 16-week blocks because that's what the primary end points of the clinical trials are," he said. "But psoriasis is a long-term disease. People have it for 20, 30, or 40 years, so we need to think beyond the realm of short-term."

Dr. Gordon disclosed that he has received research support or honoraria from Abbott, which manufactures adalimumab as Humira, as well as Amgen, Astellas, Centocor, and Genentech.

The cost of systemic therapies for psoriasis increased so fast in recent years that it outpaced the inflation rates for all items and for prescription drugs overall, according to a report in the January issue of the Archives of Dermatology.

The costs for brand name psoriasis drugs increased an average of 66% from 2000 to 2008. In comparison, the cost of other consumer items rose by 26% and that of prescription drugs overall rose by 30% during the same interval.

Much of this increase in the cost of psoriasis therapies can be attributed to the high cost of newer biologic therapies relative to that of more traditional systemic treatments. The advent of brand name versions of older drugs also has hiked treatment costs, wrote Dr. Vivianne Beyer and Dr. Stephen E. Wolverton, both of Indiana University, Indianapolis.

The investigators devised a cost model for each systemic psoriasis therapy based on continuous, yearlong outpatient treatment, including the expenses for medications, office visits, and recommended laboratory tests and monitoring procedures. They did not include the costs of treatment for adverse effects, or indirect costs such as time missed from work.

The researchers then compared the direct annual costs of phototherapy, systemic agents, and biologics from 2000 through 2008. In general, “traditional therapies remain much more affordable than biologic therapies,” they said.

It has been reported that prescription drug costs in general are outpacing the inflation rate, and “this trend also applies to therapies for psoriasis,” the investigators wrote. “Costs for all psoriasis medications except methotrexate, cyclosporine, alefacept, and infliximab have increased at a substantially greater rate” than inflation.

The annual change in the price of systemic drugs varied widely during the study period, from a net decrease of 24% in the cost of methotrexate to a net increase of 316% in the cost of Oxsoralen-Ultra, a brand name version of methoxsalen.

Acitretin showed the second-largest rise in price, an increase of 158% between 2000 and 2008.

In contrast, the cost of one brand name version of cyclosporine, Neoral, did not increase at all and the cost of another, Gengraf, dropped by 4%.

“Therapies such as acitretin, adalimumab, efalizumab, and etanercept have increased in cost steadily every year, whereas methotrexate, cyclosporine, and alefacept have seen minor, if any, increases in price since 2000,” the authors said (Arch. Derm. 2010;146:46-54).

For drugs and biologics, the annual cost of treatment in 2008 ranged from a low of $1,197 for methotrexate to a high of $27,577 for alefacept. Phototherapy costs ranged from a low of $3,083 per year for UVB to a high of $7,288 for PUVA, including induction and maintenance costs.

Dr. Beyer reported no financial conflicts of interest. Dr. Wolverton reported that he is a consultant for Eli Lilly & Co. regarding psoriasis therapy, is a consultant for Amgen Inc. regarding etanercept, and received royalties from Elsevier Publishing for a textbook on dermatology drugs.

The cost of systemic therapies for psoriasis increased so fast in recent years that it outpaced the inflation rates for all items and for prescription drugs overall, according to a report in the January issue of the Archives of Dermatology.

The costs for brand name psoriasis drugs increased an average of 66% from 2000 to 2008. In comparison, the cost of other consumer items rose by 26% and that of prescription drugs overall rose by 30% during the same interval.

Much of this increase in the cost of psoriasis therapies can be attributed to the high cost of newer biologic therapies relative to that of more traditional systemic treatments. The advent of brand name versions of older drugs also has hiked treatment costs, wrote Dr. Vivianne Beyer and Dr. Stephen E. Wolverton, both of Indiana University, Indianapolis.

The investigators devised a cost model for each systemic psoriasis therapy based on continuous, yearlong outpatient treatment, including the expenses for medications, office visits, and recommended laboratory tests and monitoring procedures. They did not include the costs of treatment for adverse effects, or indirect costs such as time missed from work.

The researchers then compared the direct annual costs of phototherapy, systemic agents, and biologics from 2000 through 2008. In general, “traditional therapies remain much more affordable than biologic therapies,” they said.

It has been reported that prescription drug costs in general are outpacing the inflation rate, and “this trend also applies to therapies for psoriasis,” the investigators wrote. “Costs for all psoriasis medications except methotrexate, cyclosporine, alefacept, and infliximab have increased at a substantially greater rate” than inflation.

The annual change in the price of systemic drugs varied widely during the study period, from a net decrease of 24% in the cost of methotrexate to a net increase of 316% in the cost of Oxsoralen-Ultra, a brand name version of methoxsalen.

Acitretin showed the second-largest rise in price, an increase of 158% between 2000 and 2008.

In contrast, the cost of one brand name version of cyclosporine, Neoral, did not increase at all and the cost of another, Gengraf, dropped by 4%.

“Therapies such as acitretin, adalimumab, efalizumab, and etanercept have increased in cost steadily every year, whereas methotrexate, cyclosporine, and alefacept have seen minor, if any, increases in price since 2000,” the authors said (Arch. Derm. 2010;146:46-54).

For drugs and biologics, the annual cost of treatment in 2008 ranged from a low of $1,197 for methotrexate to a high of $27,577 for alefacept. Phototherapy costs ranged from a low of $3,083 per year for UVB to a high of $7,288 for PUVA, including induction and maintenance costs.

Dr. Beyer reported no financial conflicts of interest. Dr. Wolverton reported that he is a consultant for Eli Lilly & Co. regarding psoriasis therapy, is a consultant for Amgen Inc. regarding etanercept, and received royalties from Elsevier Publishing for a textbook on dermatology drugs.

The cost of systemic therapies for psoriasis increased so fast in recent years that it outpaced the inflation rates for all items and for prescription drugs overall, according to a report in the January issue of the Archives of Dermatology.

The costs for brand name psoriasis drugs increased an average of 66% from 2000 to 2008. In comparison, the cost of other consumer items rose by 26% and that of prescription drugs overall rose by 30% during the same interval.

Much of this increase in the cost of psoriasis therapies can be attributed to the high cost of newer biologic therapies relative to that of more traditional systemic treatments. The advent of brand name versions of older drugs also has hiked treatment costs, wrote Dr. Vivianne Beyer and Dr. Stephen E. Wolverton, both of Indiana University, Indianapolis.

The investigators devised a cost model for each systemic psoriasis therapy based on continuous, yearlong outpatient treatment, including the expenses for medications, office visits, and recommended laboratory tests and monitoring procedures. They did not include the costs of treatment for adverse effects, or indirect costs such as time missed from work.

The researchers then compared the direct annual costs of phototherapy, systemic agents, and biologics from 2000 through 2008. In general, “traditional therapies remain much more affordable than biologic therapies,” they said.

It has been reported that prescription drug costs in general are outpacing the inflation rate, and “this trend also applies to therapies for psoriasis,” the investigators wrote. “Costs for all psoriasis medications except methotrexate, cyclosporine, alefacept, and infliximab have increased at a substantially greater rate” than inflation.

The annual change in the price of systemic drugs varied widely during the study period, from a net decrease of 24% in the cost of methotrexate to a net increase of 316% in the cost of Oxsoralen-Ultra, a brand name version of methoxsalen.

Acitretin showed the second-largest rise in price, an increase of 158% between 2000 and 2008.

In contrast, the cost of one brand name version of cyclosporine, Neoral, did not increase at all and the cost of another, Gengraf, dropped by 4%.

“Therapies such as acitretin, adalimumab, efalizumab, and etanercept have increased in cost steadily every year, whereas methotrexate, cyclosporine, and alefacept have seen minor, if any, increases in price since 2000,” the authors said (Arch. Derm. 2010;146:46-54).

For drugs and biologics, the annual cost of treatment in 2008 ranged from a low of $1,197 for methotrexate to a high of $27,577 for alefacept. Phototherapy costs ranged from a low of $3,083 per year for UVB to a high of $7,288 for PUVA, including induction and maintenance costs.

Dr. Beyer reported no financial conflicts of interest. Dr. Wolverton reported that he is a consultant for Eli Lilly & Co. regarding psoriasis therapy, is a consultant for Amgen Inc. regarding etanercept, and received royalties from Elsevier Publishing for a textbook on dermatology drugs.