Treatment practices for psoriasis and how they are changing

To the Editor: Psoriasis is a chronic inflammatory disorder for which many new treatments are available. The purpose of this study was to assess how treatment for psoriasis has been changing from 2007 through 2016. The National Ambulatory Medical Care Survey (NAMCS) is a cross-sectional survey of visits to nonfederal, ambulatory-based US physicians.1Centers For Disease Control and PreventionNational Ambulatory Medical Care Survey.ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/NAMCSDate: 2016Google Scholar We assessed the prescribed treatments at visits with International Classification of Diseases, Ninth Edition code 696.1 or International Classification of Diseases, 10th edition code L40.9 listed among the 5 leading diagnoses.22014 micro-data file documentation.https://data.nber.org/namcs/docs/namcs2014.pdfGoogle Scholar Data were analyzed by using SAS University Edition (SAS Institute, Cary, NC). To correct for multiple hypothesis tests performed, the standard alpha value of .05 was reduced to .005 by the Bonferroni correction.3Leon A.C. Multiplicity-adjusted sample size requirements: a strategy to maintain statistical power with Bonferroni adjustments.J Clin Psychiatry. 2004; 65: 1511-1514Crossref PubMed Scopus (31) Google Scholar There were 935 visits, representing 23.2 (95% confidence interval [CI], 21.8-24.7) million visits. There were 12.1 (95% CI, 10.7-13.4) million visits by female patients, which was 51.9% (95% CI, 46.1-57.7) of the total. The most common race was white (68.9%; 95% CI, 63.4-74.4). There were 2.32 million visits per year and no change in visit frequency with an increase in the study year (P = .2). Topical medications were listed at about half of all visits (Fig 1). The use of topical agents decreased (P < .001) by an estimated 0.23% (95% CI, 0.16-0.30) per year (Table I and Fig 1). There was also a decrease in the use of topical corticosteroids (P < .001) and vitamin D analogs (P < .001) but not topical calcineurin inhibitors (P = .04). Topical corticosteroids represented 75% (95% CI, 68-82) of all topical medications observed, vitamin D analogs represented 28% (95% CI, 26-30), and calcineurin inhibitors represented 7.1% (95% CI, 5.4-8.5).Table IOdds ratios for treatment modalities based on a 1-year increase in the study intervalTreatment typeOdds ratio (95% CI)Topical medications overall0.87 (0.83-0.91)∗Indicates P < .05.Topical corticosteroids0.90 (0.86-0.95)∗Indicates P < .05.Topical vitamin D analog0.75 (0.66-0.85)∗Indicates P < .05.Topical calcineurin inhibitor0.86 (0.74-0.99)∗Indicates P < .05.Systemic corticosteroids0.89 (0.77-1.0)∗Indicates P < .05.Adalimumab1.3 (1.0-1.6)∗Indicates P < .05.Infliximab1.9 (1.1-3.3)∗Indicates P < .05.Etanercept0.9 (0.76-1.1)Ustekinumab0.79 (0.48-1.3)Secukinumab—Acitretin0.95 (0.70-1.3)Apremilast1.4 (0.04-53)Cyclosporine0.76 (0.58-0.99)∗Indicates P < .05.Methotrexate0.92 (0.80-1.1)Phototherapy.92 (0.78-1.2)CI, Confidence interval.∗ Indicates P < .05. Open table in a new tab CI, Confidence interval. Systemic medications were listed at about a quarter of all visits (Fig 1). Biologics were listed at 12% (95% CI, 9.7-14) of all visits for psoriasis, with systemic corticosteroids at 7.1% (95% CI, 5.4-8.8) and other small molecule drugs at 8.6% (95% CI, 7.1-10). There was a 1% to 2% increase in visits with adalimumab and infliximab (P = .03), which was not significant after correcting for multiplicity. There were fewer visits over time for cyclosporine (P = .04). There was no change in visits at which etanercept (P = .2), ustekinumab (P = .3), acitretin (P = .8), apremilast (P = .9), and systemic corticosteroids (P = .7) were used. Phototherapy was listed at a small fraction of visits (Fig 1), and there was no change in use over time (P = .3). A limitation of this study was that estimating changes in visits required unassigning and reassigning the weighting variable. Therefore, these estimates are more useful for their directionality and magnitude and not as detailed estimates of high accuracy. Because 7.4 million people in the United States have psoriasis,4Rachakonda T.D. Schupp C.W. Armstrong A.W. Psoriasis prevalence among adults in the United States.J Am Acad Dermatol. 2014; 70: 512-516Abstract Full Text Full Text PDF PubMed Scopus (480) Google Scholar most patients with psoriasis do not seek ambulatory care in a given year. Since most people with psoriasis have mild disease,5Stern R.S. Nijsten T. Feldman S.R. Margolis D.J. Rolstad T. Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction.J Investig Dermatol Symp Proc. 2004; 9: 136-139Abstract Full Text Full Text PDF PubMed Scopus (573) Google Scholar our study supports the finding that many patients with mild disease do not seek treatment. Topical agents are the most commonly used treatments; however, their use is decreasing modestly, whereas biologic use is increasing. As more biologic treatments become available, we expect these trends may continue past the end of the study interval and increase in magnitude over time. Systemic corticosteroid use is common, whereas phototherapy has been and continues to be an infrequent and perhaps underused treatment. Trends in psoriasis treatments may differ for new and established patientsJournal of the American Academy of DermatologyVol. 85Issue 1PreviewTo the Editor: We read with interest the article by Muddasani et al,1 “Treatment practices for psoriasis and how they are changing,” which investigated psoriasis treatment trends using data from the National Ambulatory Medical Care Survey from 2007 to 2016. The authors found an increase in the use of biologics, a decline in topical therapy use, and no change in phototherapy, acitretin, and apremilast use. In our study, “Trends in psoriasis treatment 2005 to 2018: Declining phototherapy utilization and concomitant increased use of biologics,” which was conducted in a large New York City academic center between 2005 and 2018, we identified some similar psoriasis treatment trends. Full-Text PDF