Access To Health Care in Patients With Psoriasis - 2013 - Journal of The Americ

P6973 PD02—PSORIASIS
Our experience regarding muscle weakness in the treatment of palmar

hyperhidrosis with botulinum toxin type A
Charitomeni Vavouli, Andreas Sygros Hospital, Athens, Greece; Evgenia Balamoti,
P6741
Andreas Sygros Hospital, Athens, Greece; George Kontochristopoulos, Andreas Access to health care in patients with psoriasis: Data from National
Sygros Hospital, Athens, Greece; Vasiliki Markantoni, Andreas Syggros Hospital, Psoriasis Foundation survey panels
Athens, Greece Tina Bhutani, MD, University of California, San Francisco, Department of
Background: Botulinum A toxin (BT/A) is a therapeutic option in focal hyperhidro- Dermatology, San Francisco, CA, United States; April W. Armstrong, MD, MPH,
sis. Muscle weakness (MW) observed with this therapeutic method is a temporary University of California, Davis, Department of Dermatology, Sacramento, CA,
side effect. This study aims to show the high incidence of MW and the potential United States; Bruce F. Bebo, Jr, PhD, National Psoriasis Foundation, Portland,
factors that appear to affect it. OR, United States; Jillian W. Wong, MS, University of Utah School of Medicine,
Salt Lake City, UT, United States
Methods: During a 2-year period (2008-2010), 474 moderate and serious incidents of
palmar hyperhidrosis were treated at A.Sygros Hospital (312 females and 162 males; Background: We aimed to examine the relationship between psoriasis patient
14-62 years of age; average age, 29.7 years). Two hundred nine patients reported a characteristics and access to care and to determine patients’ out-of-pocket spending
positive family history (46.4%). All patients were subjected to starch-iodine test and for psoriasis treatment.
cryoanalgesia with dichlorotetrafluorethane nebulizer. BT/A was injected intrader- Methods: Thirteen semiannual surveys were conducted among patients with
mally at a dose of 100 to 120 U, on average, with insulin syringes of 0.5 mL, at a psoriasis and psoriatic arthritis who are members of the National Psoriasis
distance between the points of 2 cm. An injection was performed per finger phalanx Foundation from 2003 to 2009 and 2011. The survey participants were identified
and extra injections at the last phalanx and the ulnar border of palm (2.5 U or 0.1 mL by random sampling of more than 75,000 psoriasis patients. Approximately 400
per injection site). interviews were conducted per survey, with half occurring over the phone and half
Results: The efficiency of the treatment was assessed to be between 75% and online. The data used in this analysis consist of compiled data from all available
100%. Regarding the side effects of the treatment, local pain was reported by 433 survey panels. STATA computer statistical package, version 12, was used for all
patients (91.33%) and the majority characterized it as moderate. Twenty-nine statistical analysis. Main outcome measures included the number and type of
patients exhibited local bruising (6.1%), and 3 patients developed reactive physicians seen in the last 2 years, and out-of-pocket health care expenses were
hyperhidrosis (0.6%). MW occurred in 131 cases (27.6%), with half having measured.
reported a family history of focal hyperhidrosis (among patients with MW, 64 Results: Among 5,604 patients with psoriasis and psoriatic arthritis, 92% of psoriasis
reported a positive history and 65 reported a negative history). The average age patients had seen at least 1 physician in 2 years. Compared to males, female psoriasis
of appearance of MW is 30 years (26.8 for men and 32 for women). Among the patients were 1.47 times more likely to seek care (adjusted odds ratio [OR], 1.47;
patients who developed MW, 99 were women and the remaining 32 were men 95% confidence interval [CI], 1.18-1.83). Patients with private insurance and
(ie, the incidence of MW for the female population of the study is 31.7% and Medicare were more likely to seek care compared to uninsured patients (adjusted
19.7% for the male population). The onset of symptoms was 5 to 7 days after the OR, 3.02; 95% CI, 2.23-4.08; adjusted OR, 2.85; 95% CI, 1.91-4.24, respectively).
injection, and lasts 2 to 5 weeks. Among psoriasis patients seeking care, 78% were seeing specialists; 22% obtained
Conclusion: Hypothetical causes of MW could be include genetic predisposition, care from primary care physicians. Primary reasons for not seeking treatments
gender, age, and diffusion of drug in the underlying muscles, etc. BT/A included giving up on disease treatment (28%) and prohibitive cost (21%).
constitutes a reliable therapeutic method for moderate and severe focal Compared to patients with mild disease, patients with severe psoriasis were more
hyperhidrosis, improves the quality of life, and is positively evaluated by the likely to seek a specialist for care (adjusted OR, 1.64; 95% CI, 1.37-1.98). Patients
patients. Most patients would repeat the treatment. MW and other side effects spent an average of $2528 out-of-pocket per year for psoriasis care.
do not seem to be a restrictive factor, probably because of their transient Conclusions: Nearly a quarter of patients seek psoriasis care from primary care
nature. providers, and insurance status affects care-seeking patterns. Giving up on
treatment and prohibitive costs remain primary reasons for not seeking care.
Commercial support: None identified.
Commercial support: None identified.
P6834
Cost-effectiveness of biologic therapies for plaque psoriasis: A systematic
review
Christine Ahn, Wake Forest School of Medicine, Winston-Salem, NC, United
States; Cheryl Gustafson, MD, Wake Forest School of Medicine, Winston-Salem,
NC, United States; Scott Davis, Wake Forest School of Medicine, Winston-Salem,
NC, United States; Steven Feldman, MD, PhD, Wake Forest School of Medicine,
Winston-Salem, NC, United States
Background: The use of biologic agents has changed the therapeutic management of
severe plaque psoriasis. In addition to clinical efficacy, biologics are associated with
higher costs than traditional therapy. Therefore, when assessing the clinical efficacy
of biologic agents, it is important to consider their cost-effectiveness.
Purpose: To determine the cost-effectiveness of biologic agents, measured by the
cost per patient achieving a minimally important difference in the Dermatology Life
Quality Index (MID DLQI) and cost per patient achieving a 75% improvement in the
P7122 Psoriasis Area Severity Index (PASI-75).
The versatility of the nasolabial transposition flap in midfacial recon-
Methods: A PubMed literature search was conducted to identify randomized
struction: Our experience placebo-controlled clinical trials describing the efficacy of FDA-approved biologic
Diogo Matos, MD, Hospital Garcia de Orta, Almada, Portugal; Jo~ao Goul~ao, MD, therapies. Cost-effectiveness was determined by the cost per patient achieving a
Hospital Garcia de Orta, Almada, Portugal MID DLQI and PASI-75 after 12 weeks of treatment. A sensitivity analysis was
The nasolabial flap is an ellipse-shaped transposition flap centered in the performed to compare cost-effectiveness ratios. Treatment paradigms were extrap-
nasolabial fold. Technically not very demanding, it has a high viability and a olated to estimate cost-effectiveness of 1 year of treatment.
favourable security profile because of its vascularization by the angular artery Results: Twenty-seven trials evaluating adalimumab, alefacept, etanercept, inflix-
and the depth of the surrounding nervous structures. Superiorly based nasola- imab, and ustekinumab were included in this study. Infliximab 3 mg/kg IV (weeks 0,
bial flaps can be used for reconstruction of a wide range of midfacial surgical 2, and 6) was the most cost-effective agent achieving a MID DLQI at 12 weeks,
defects. At our dermatology department, during the year of 2010, 78 flaps were followed by etanercept 25 mg SQ once weekly and infliximab 5 mg/kg IV. The most
performed in the setting of reconstructive oncologic surgery of the face, 48 of cost-effective agents achieving a PASI-75 were infliximab 3 mg/kg IV and
them in the midfacial area. Of these, 20 (42%) were nasolabial flaps, which adalimumab 40 mg SQ every other week (with or without 80-mg loading dose).
were used mainly for nasal reconstruction (18) but also for infraorbitary defects. The annual cost of biologic treatment ranged from $6800 for low dose alefacept to
This flap was used for all the anatomic subunits of the nose, including the $56,000 for high dose ustekinumab. Infliximab 3 mg/kg IV had the lowest annual
dorsum and the tip, at least once. In addition to its classical usage as a cost per patient achieving both a MID DLQI and PASI-75. The least cost-effective
transposition flap, the nasolabial flap was also used as a turn-in and turn-over treatment paradigm for DLQI and PASI outcomes was alefacept.
flap for the nasal ala, and as a tunnelled flap for the tip of the nose. No cases of
loss of viability or major surgical complications were reported. All patients had Limitations: This study is limited by the lack of head-to-head trials that determine
a follow-up of $ 1 year, and the majority showed a very satisfactory cosmetic accurate relative efficacies. In addition, this study did not incorporate indirect costs
and functional outcome, without the need of reintervention. The analysis of our or variation in costs caused by insurance company contracting.
data highligts the versatility of the nasolabial flap in the midfacial reconstruction Conclusion: Infliximab 3 mg/kg IV had the most favorable cost-effectiveness profile,
as this flap was used in surgical defects affecting different structures of the with the lowest cost per patient achieving both a MID DLQI and PASI-75. Other
midface, particularly the nose. Because of its versatility, viability, and security biologic agents foundd small differences in cost-effectiveness, likely to be over-
profile, the nasolabial flap is a must-know flap for all the dermatologic surgeons, whelmed by individual variation, insurance company price contracting, and the
because it constitutes a very useful and easy to master tool in facial uncertainty inherent with the lack of head-to-head trials to determine relative
reconstruction. efficacy.
Commercial support: None identified. Commercial support: None identified.
AB2 J AM ACAD DERMATOL APRIL 2013

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P6973 PD02—PSORIASIS

Our experience regarding muscle weakness in the treatment of palmar

Commercial support: None identified. Commercial support: None identified.

AB2 J AM ACAD DERMATOL APRIL 2013

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