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Cost effectiveness of home ultraviolet B phototherapy for psoriasis:  economic evaluation of a randomized controlled trial (PLUTO study)

Published in the April 20, 2010 issue of the BMJ.  Reference BMJ 2010;340:c1490.  Mayke B G Koek, MD, author. This research report describes the economic conclusions of a study on home phototherapy for psoriasis versus phototherapy delivered in a clinical setting (see Daavlin synopsis entitled Recent Trends in Systemic Psoriasis Treatment Costs).The first report described the therapeutic findings of the study which showed that home phototherapy was as safe and effective as clinically delivered phototherapy. In this report, the author cost quantified issues such as quality adjusted life years and the number of days with a relevant treatment effect.  In effect, the study determined what it cost to give the patient a better life. The results showed very little difference in actual cost and cost effectiveness between home and clinic based delivery of phototherapy for psoriasis. Based on the study, the author concluded that home phototherapy should be a primary treatment option for qualified patients since patients prefer home phototherapy and because it is as safe, effective, and cost effective as clinically delivered phototherapy. We must note that the economic conclusions in this study were based on costs in the Netherlands, which may be different than costs in other countries.


Recent Trends in Systemic Psoriasis Treatment Costs

Vivianne Beyer, MD, Stephen E. Wolverton, MD Archives of Dermatology/Volume 146 (no.1) January 2010

This study undertook a comprehensive analysis of the annualized costs of various systemic therapies for the treatment of moderate-to-severe psoriasis.  The analysis included adjunctive therapies and monitoring costs typically associated with each of the therapies studied.  The authors collected cost data through the years 2000 to 2008 and compared the cost increases for psoriasis drugs to those of drugs in general and to the urban consumer price index.  At an annualized cost of $1,393, Methotrexate was determined to be the least expensive therapy, following closely by UVB therapy at $1,414.  PUVA therapy was over twice as expensive as UVB therapy but still inexpensive compared to Alefacept (Humira), which was the most costly therapy at $27,577.  However, this analysis was based on published recommended regimens.  When commonly prescribed regimens are included in the analysis, Raptiva, although now removed from the market, had a calculated annual cost of $48,530.  Over the period of the study, the consumer price index increased by 26%, prescription drugs overall increased by 30% and, in the same period, psoriasis drugs increased by an average of 52% meaning that psoriasis drugs have increased in cost at double the rate of the consumer price index. Note:  Some of these therapies, such as PUVA and Narrow Band UVB are significantly more effective than others.  This study did not attempt to analyze the cost per successful outcome for each of the therapies.


An article by Rachel S. Hotard, et.al. reflected on the differences in treatment of severe psoriasis in men and women, finding that there were no notable differences when a topical treatment was prescribed. However, when treatments such as methotrexate and etretinate were used, men were the primary receivers. Women were more likely to receive PUVA or isotretinoin treatments. Women over 50 were more likely to receive more intensive therapy than men. The difference in the treatment of psoriasis between men and women is believed to be a result of reluctance to use a potentially teratogenic therapy in women of childbearing age. (J Am Acad Dermatol 2000;42:620-3)


A study conducted by Pravit Asawanonda, MD, DSc, and Yaowalak Nateetongrungsak, MD revealed that when methotrexate (MTX) is used in conjunction with narrowband UVB phototherapy it clears more cases of psoriasis and requires significantly fewer treatments than when narrowband UVB phototherapy is used alone. Since MTX doses are very low it can be used for years before the cumulative doses pose any risk of hepatoxicity all the while reducing the scaliness and the thickness of the lesions.  (J Am Acad Dermatol 2006; 54:1013-8)


In an article by Elizabeth M. Kass, M.D. in the May 2007 issue of Skin and Aging, the obstacles of treating psoriasis were found to be mainly cost and time factors for both patients and physicians. To alleviate the problems for the patients Kaiser Permanente in California has implemented new strategies such as opening multiple service centers for ease of travel, extending office hours to help with tight schedules and eliminating the co-payment. The savings on the more costly alternatives to light treatment far outweighed the loss of revenue resulting from waived co-pays.


“Narrowband UV-B (TL-01) Phototherapy vs Oral 8-Methoxypsoralen Psoralen-UVA for the Treatment of Chronic Plaque Psoriasis” (T. Markham, MB, MRCPI et.al) March 2003 issue of the Archives of Dermatology. The objective of this study was to compare the efficacy of Narrow Band UVB phototherapy to PUVA therapy in patients with chronic plaque type psoriasis. Forty five patients completed the open, randomized study. Those in the PUVA group required significantly fewer treatments to clear but there was no significant difference in the number of days to clear or the number of days in remission. The Narrow Band UVB patients were treated three times per week versus twice per week for the PUVA patients. Side effects, including erythema, pruritis and polymorphic light eruption occurred equally in both groups. Nausea was associated with the PUVA group only. The authors conclude by recommending Narrow Band UVB as the phototherapy of choice for patients with chronic plaque type psoriasis.


“Targeted UV-B Phototherapy for Plaque-type Psoriasis” (Pravit Asawanonda, MD, DSc et al.) December 2005 issue of Archives of Dermatology. The authors found that using targeted UV-B phototherapy to deliver treatments to specific locations on the body is of benefit to patients who suffer from localized recalcitrant disease. It offers high dose irradiation treatments to the infected regions of the body without exposing the surrounding unaffected skin. The beam profile makes the treatments easier to perform with very homogeneous clearing of the lesions. Although there was no evidence of serious adverse reactions to the treatments, the long term byproducts of such high-dose irradiation are difficult to determine.


An article in the August 1999 issue of The Chronicle of Skin Disease reports that it takes fewer treatments to clear psoriasis vulgaris with Narrow Band UVB than it does with conventional broad band UVB and that there is no statistically significant difference between the two lamps regarding phototoxicity. These results were reported by Dr. Lori Hobbs, clinical research fellow in Dermatology at Vancouver General Hospital, at the 74th annual meeting of the Canadian Dermatology Association in Vancouver.


Dr. Adrian Tanew of the Division of Special and Environmental Dermatology at the University of Vienna (Austria) found that Narrow Band UVB is nearly as effective as PUVA in treating plaque-type psoriasis. Reported in the Archives of Dermatology 135[5]:519-24, 1999, he states, “Our data demonstrate that in many patients, in particular those with moderate or moderate to severe psoriasis, narrow band UVB is comparably as effective as PUVA, whereas in the more severely affected, PUVA is superior.”


Dr. Henry W. Lim, chairman of dermatology at the Henry Ford Hospital in Detroit reported that “Narrow-band ultraviolet B light may carry no greater carcinogenic risk than broad band UVB when used to treat psoriasis.” “Animal studies have determined that narrow band UVB is two to three times more carcinogenic per minimal erythemal dose (MED) than its broad band counterpart. When compared with broad band UVB, however, less MED-equivalents of narrow band UVB are needed to clear psoriasis in humans.” These remarks were made at the annual colloquium on clinical dermatology (sponsored by the Dermatology Foundation) and reported in the July 1998 issue of Skin & Allergy News.


Photodermatol Photoimmunol Photomed: 1999:15:81-84 Charles L.G. Halasz, Department of Dermatology, College of Physicians & Surgeons of Columbia University, New York, NY. “In summary, using a conservative fixed increment regimen, clearing of psoriasis is possible while minimizing the risk of serious erythema. It is the author’s opinion that, compared to traditional broad band phototherapy, narrow band phototherapy leads to earlier clinical improvement resulting in enhanced compliance with treatment and lower drop-out rates.”


Journal of the American Academy of Dermatology, 1999;40:893-900. In an article entitled “Suberythemogenic narrow band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris”, Dr. Ian B. Walters and others of the Laboratory for Investigative Dermatology, The Rockefeller University, reported that eleven patients were treated using a split-body approach for 6 weeks on a three-times-a week basis. Using suberythemal doses of narrow band UVB, they were able to induce clinical clearing in 81.8% of patients after NB-UVB, but in only 9.1% of patients after BB-UVB. They concluded that NB-UVB is superior to UVB-BB in reversing psoriasis at suberythemogenic doses when given three times per week.


Archives of Dermatology, 1997;133:1514-1522. In an article entitled “Narrowband UV-B Produces Superior Clinical and Histopathological Resolution of Moderate-to Severe Psoriasis in Patients Compared With Broadband UVB-B”, Dr. Todd R. Coven and others of the Laboratory for Investigative Dermatology, The Rockefeller University concluded “that Narrowband UV-B offers a significant therapeutic advantage over BB UV-B in the treatment of psoriasis, with faster clearing and more complete disease resolution. The erythemal response to NB UVB treatment was significantly more intense and persistent compared with BB UVB.


Skin and Allergy News, reporting from the annual meeting of the West Virginia Dermatological Society, quoted Dr. Thomas Fitzpatrick, Professor Emeritus of Dermatology at Harvard University: “Bulbs that emit a narrow band of ultraviolet light in the UVB range appear to be superior to traditional broad band UVA for the treatment of psoriasis.”


Journal of the American Academy of Dermatology 1997;36:577-81. D.A.R de Berker and others report in an article entitled “Comparison of psoralen-UVB and psoralen-UVA photochemotherapy in the treatment of psoriasis” that in a study of 100 patients with plaque-type psoriasis, “no significant difference was found between the two treatments [psoralen-UVB and psoralen-UVA] in the proportion of patients whose skin cleared during treatment or in the number of exposures required for clearance of psoriasis.” “Side effects and disease status at 3 months after the end of treatment were similar for the two groups”


Skin and Allergy News, November 1997. Dr. Robert Rietschel, chairman of the department of dermatology at Oschner Clinic in New Orleans, reported at the annual meeting of the South Central Dermatological Congress, that “I’ve been very pleased with it [Narrow Band UVB] and highly recommend it. It may be the only light source you’ll need.” The article goes on to report that “Not only are the results as good with PUVA, but it obviates the nausea and cost associated with oral psoralen. It does not carry the same risks of photosensitivity, does not require eye protection except for during the treatment itself and does not require ophthalmologic checkups. Pregnant women and children can be treated.”


Photodermatol Photoimmunol Photomed 1997: 13: 82-84. In an article entitled “Narrow-band (311 nm) UVB phototherapy: an audit of the first year’s experience at the Massachusetts General Hospital” MBT Alora and CR Taylor, both from the Phototherapy Unit, Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA, state: “In summary, published reports of controlled narrow band studies have all shown superior clinical results with minimal risk of burning. Our preliminary findings suggest that caution must be exercised in using this modality, especially when patients miss treatments or the irradiation protocols are aggressive. Careful attention to dosimetry is essential and patients should be encouraged to express any, even minor symptoms, which may result from their last treatment as we have seen a clear threshold phenomenon even with strict adherence to standard protocols.”


Private communication written by Edmond I, Griffin, M.D. and others, from Atlanta, Georgia, USA. ” The Dermalight Psora-Comb was used in a group of 13 patients with moderate to severe scalp psoriasis. Also included was 1 patient with chronic persistent seborrhea. The group of 14 patients all received scalp phototherapy as part of an intensive scalp therapy program.” ” In this group, the average treatment time at clearing was 9 minutes and 20 seconds. The average number of treatments needed to provide clearance was 20, with the highest being 32 and lowest being 10. Periods of remission were reported in the group, with 57% experiencing remissions for 1-16 months, while the remaining 43% were lost to follow up or discontinued treatment altogether.” “In conclusion, we have found the Psora-Comb to be an effective instrument in our scalp therapy program, especially when used with short contact anthralin therapy or psoralens either together or separately.”


G Ital Dermatol Venereol, 1989;124:LXI-LXV. In an article published in Italy entitled “Fototerapia della psoriasis del cuoio capelluto” by Dr. M. Caccialanza and others at the University of Milan, they state, “The presence of hair hampers the performance of photo-and photochemotherapy and blocks the efficacy of exposure to sunlight in patients affected by scalp psoriasis. A portable source of ultra-violet rays was tested on 21 patients: the device is equipped with a special comb which, by separating the hair, partially overcomes the protective shield formed by the latter.” They further report that “A complete remission of dermatosis was achieved in 6 cases, a marked improvement in 11 (50-95%), and a slight improvement in 4 (20-30%). The source used was found to be efficacious especially in those forms of slight to medium psoriasis of the capillitium; it was handy and easy to use making it suitable for home use.”

 

Eczema Excerpts

The Skin and Allergy News, May 1999 reports that “Narrow-Band UVB May Benefit Atopic Dermatitis.” Dr. Craig A. Elmets of the University of Alabama at Birmingham stated at the colloquium on clinical dermatology that “The single-frequency, 311-nm light source is ‘nearly as effective as PUVA in atopic dermatitis patients, with potentially fewer side effects…[but] still has an unproven safety record.”


The British Journal of Dermatology (1993) 128, 49-56 reported in an article by Dr. S.A. George and others (Photobiology Unit, Department of Dermatology, Ninewells Hospital and Medical School, Dundee, UK.) that a 12 week course of Narrow Band UVB resulted in a 68% reduction in atopic dermatitis severity scores. The article concluded that “Narrow-band UVB (TL-01) phototherapy appears an effective, steroid-sparing treatment for chronic severe atopic dermatitis, offering long-term benefits in the majority of those treated.”

Miscellaneous Excerpts

Mycosis Fungoides.

An article in Skin and Allergy News reported on a presentation by Dr. Jane J. Kim of the Henry Ford Health System (Detroit) that “Narrow-band UVB phototherapy shows potential as a novel therapeutic option for patients with stage I mycosis fungoides…” The article goes on to state that “…three such patients each showed greater than 70% improvement after a mean of 18 narrow band treatments, with clinical remission achieved after a mean of 30 treatments, or 14.5 weeks” which is quicker than broad band UVB. The same article also presents information on positive results in Vitiligo and Atopic Dermatitis using Narrow Band UVB therapy.


PUVA and Cataracts.

“Psoralen plus ultraviolet A does not increase the risk of cataracts: A 25-year prospective study” (Dimitrios Malanos, MD and Robert S. Stern, MD) J Am Acad Dermatol 2007; 57:2. The authors found no significant correlation between PUVA exposure and the development of cataracts among middle-aged and older persons undergoing treatment while using eye protection (emphasis added). Since there were no younger persons enrolled in this study, the effect of PUVA on the eyes of younger people could not be determined at this time.

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