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Original Investigation |

Undertreatment, Treatment Trends, and Treatment Dissatisfaction Among Patients With Psoriasis and Psoriatic Arthritis in the United States:  Findings From the National Psoriasis Foundation Surveys, 2003-2011

April W. Armstrong, MD, MPH1; Andrew D. Robertson, PhD2; Julie Wu, BS1; Clayton Schupp, PhD1; Mark G. Lebwohl, MD3
[+] Author Affiliations
1Department of Dermatology, University of California–Davis, Sacramento
2National Psoriasis Foundation, Portland, Oregon
3Department of Dermatology, Mount Sinai School of Medicine, New York, New York
JAMA Dermatol. 2013;149(10):1180-1185. doi:10.1001/jamadermatol.2013.5264.
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Importance  Psoriasis and psoriatic arthritis inflict significant morbidity. Data on undertreatment, treatment use, and treatment satisfaction are paramount to identify priority areas for advocacy, education, and research to improve patient outcomes.

Objectives  To determine the extent of nontreatment and undertreatment of psoriatic diseases, trends in treatment use, treatment satisfaction, and reasons for medication discontinuation among patients with psoriasis and psoriatic arthritis.

Design, Setting, and Participants  We used the national survey data collected by the National Psoriasis Foundation via biannual surveys conducted from January 1, 2003, through December 31, 2011, in the United States. Survey data were collected from randomly sampled patients with psoriasis and psoriatic arthritis in the US population from a database of more than 76 000 patients with psoriatic diseases.

Main Outcomes and Measures  Nontreatment, undertreatment, and treatment trends determined by the use of prescription medication (topical, phototherapeutic, oral systemic, and biologic), as well as treatment satisfaction and reasons for medication discontinuation.

Results  A total of 5604 patients with psoriasis or psoriatic arthritis completed the survey. From 2003 through 2011, patients who were untreated ranged from 36.6% to 49.2% of patients with mild psoriasis, 23.6% to 35.5% of patients with moderate psoriasis, and 9.4% to 29.7% of patients with severe psoriasis. Among those receiving treatment, 29.5% of patients with moderate psoriasis and 21.5% of patients with severe psoriasis were treated with topical agents alone. The most frequently used phototherapy modality is UV-B, whereas methotrexate is the most commonly used oral agent. Although adverse effects and a lack of effectiveness were primary reasons for discontinuing biological agents, the inability to obtain adequate insurance coverage was among the top reasons for discontinuation. Overall, 52.3% of patients with psoriasis and 45.5% of patients with psoriatic arthritis were dissatisfied with their treatment.

Conclusions and Relevance  Nontreatment and undertreatment of patients with psoriasis and psoriatic arthritis remain a significant problem in the United States. While various treatment modalities are available for psoriasis and psoriatic arthritis, widespread treatment dissatisfaction exists. Efforts in advocacy and education are necessary to ensure that effective treatments are accessible to this patient population.

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Figure 1.
Proportions of Respondents With Psoriasis Receiving No Treatment or Using Topical Medications Alone by Severity Level

Psoriasis severity was categorized as mild (<3% body surface area [BSA] involvement of psoriasis), moderate (3%-10% BSA), or severe (>10% BSA).

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Figure 2.
Psoriasis Patients’ Self-reported Reasons for Receiving Only Topical Medications

Psoriasis patients were queried as to why they were using topical therapy alone in 2007.

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Figure 3.
Trends in Phototherapy and Laser, Oral Systemic Medication, and Biological Agent Use Over Time

PUVA indicates psoralen–UV-A.

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Figure 4.
Patient Dissatisfaction With Psoriasis Treatments by Severity Level

Treatment dissatisfaction was assessed among psoriasis patients.

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Figure 5.
Top Reasons for Discontinuation of Biological Medication

The 2007 and 2008 data are compared.

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