Many patients with psoriasis and psoriatic arthritis are not benefiting from the expanding array of treatments now available to combat these serious autoimmune disorders, researchers led by a UC Davis dermatologist report in a new study published online today by JAMA Dermatology.
"The high proportion of patients who are not being treated, or are being inadequately treated, is a concern because psoriasis is much more than a cosmetic skin condition." said April W. Armstrong, lead author of the study and an associate professor of dermatology at UC Davis. "It's a serious and chronic medical disease."
Patients with psoriasis are at high risk for heart attacks, diabetes and premature death as well as joint inflammation leading to arthritis, added Armstrong, who also serves as vice chair and director of Dermatology Clinical Research Unit at UC Davis.
"Psoriasis afflicts about 7.5 million Americans and is responsible for over 11,000 cardiovascular disease deaths each year in the U.S." said Armstrong.
The disease often appears as thick, red skin with flaky, silver-white patches. An estimated 10 to 30 percent of those suffering from psoriasis develop psoriatic arthritis, which can damage the body's joints and result in physical and functional impairment.
Prescription drugs, including protein-based medications known as biologics, can help curb the excessive inflammation that underlies the skin lesions of psoriasis and that damages the joints, heart and liver of patients with the disease. The condition's abnormal inflammation associated with psoriasis results from the immune system mistakenly attacking and destroying the body's healthy tissue.
"Biologics are very effective at clearing the skin and protecting the joints against destruction, and the data from many registries show that biologics reduce a patient's risk of heart attack," said Mark G. Lebwohl, the study's senior author and professor and chair of dermatology at Mount Sinai Medical Center in New York City.
Lebwohl, Armstrong and their research colleagues analyzed the responses of more than 5,600 randomly selected patients from 13 biannual surveys, which were conducted by the National Psoriasis Foundation (NPF) between 2003 and 2011.
The analyses revealed that during those years up to 49 percent of patients with mild psoriasis, up to 36 percent of patients with moderate psoriasis, and up to 30 percent of patients with severe psoriasis reported that they were not receiving any therapy for their conditions.
Patients with moderate-to-severe psoriasis often need systemic therapies as well as topical treatments to control their disease. However, according to the surveys, among psoriasis patients who received treatment, 30 percent of the patients with moderate psoriasis were on topical therapy alone, and 22 percent of patients with severe psoriasis were on topical treatments alone. Armstrong said that patients with moderate-to-severe psoriasis are often those who require more than just topical treatments to control their psoriasis. However, many patients have difficulty obtaining adequate systemic treatment due to health-insurance constraints.
"Unfortunately, there are real barriers that prevent patients from being treated," said Lebwohl. "Nearly every practicing dermatologist in the U.S. has written a prescription that has been denied by an insurance company."
Lebwohl added that even though phototherapy is a safe and effective therapy, it is no longer widely used because of the high co-payments charged by insurance companies and their low reimbursement rates for the physician's cost of providing the treatment, According to the American Academy of Dermatology, less than a third of practicing dermatologists now offer phototherapy as a treatment option for psoriasis.
To help address the treatment challenges for psoriasis and psoriatic arthritis suffers, the study's authors encourage more patient advocacy, especially directed at payers such as Medicare and insurance companies. They also emphasize the need for more patient education and awareness about the risk cardiovascular disease.
"We want payers to understand the serious medical consequences of non-treatment and under-treatment of psoriasis and psoriatic arthritis," said Armstrong. "There are also psychiatric consequences to these conditions. Patients often become depressed and some even suicidal because their quality of life is so poor."
The survey also found that 50 percent of psoriasis patients and 40 percent of psoriatic arthritis patients were dissatisfied with their treatment regimens. Armstrong and her colleagues suggest that the high level of dissatisfaction may be due in part to ineffective therapies or patients not understanding that psoriasis and psoriatic arthritis are chronic diseases, with symptoms that typically come and go even during clinical treatment.