Differences in wage earnings between psoriasis patients on biologics versus those on oral therapies: a population-based study in the United States.

INTRODUCTION: A critical gap exists in determining how various systemic treatments may differentially impact patients' wage earnings. METHODS: We compared personal economic indicators (annual and hourly wages, weekly hours worked, and disability days) between psoriasis patients on biologic therapies versus those on oral medications. Using the 2003-2015 Medical Expenditure Panel Survey, we performed multivariate linear regression analyses to investigate the relationship between personal economic indicators and psoriasis treatment. RESULTS: The number of U.S. respondents with psoriasis who reported using biologic or oral therapies between 2003 and 2015 was 2,638,681 (weighted). The mean annual wage among patients on biologics ($52,141.34 [95% CI 40,976-63,306]) was significantly higher than that of patients on oral therapies ($33,584.87 [95% CI 27,687-39,483]) (p=.019). The mean weekly hours worked among patients on biologics (43.7 h [95% CI 40.01-47.47]) was significantly higher than that of patients on oral therapies (40.6 h [95% CI 39.66-41.59]) (p = .003). Hourly wage and disability days were not significantly different between the two groups. CONCLUSIONS: Psoriasis patients on biologics earned higher annual wages compared to those on oral therapies, and this is primarily due to the increased number of work hours by those on biologic therapies.

Comparison of physical and mental functioning among moderate-to-severe psoriasis patients on biologic versus oral therapy.

With the extensive variety of available treatments for psoriasis, it is paramount that clinicians understand the differences between therapies. A critical literature gap exists regarding the effects of different systemic therapies on physical and mental functioning in the US psoriasis population. We sought to compare the impact of biologic versus oral therapy on measures of physical and mental functioning among US adults with moderate-to-severe psoriasis. We performed a nationwide, cross-sectional study of 2,431,282 (weighted) (183 non-weighted) US adults with psoriasis on biologic or oral therapy using the 2003-2015 Medical Expenditure Panel Survey (MEPS). Physical and mental functioning were measured with the Short Form-12 version 2 (SF-12v2) Physical Component Summary (PCS) and Mental Component Summary (MCS), respectively. The mean PCS score among patients on biologic therapy was significantly higher than that of patients on oral therapy (46.25 [95% CI 43.91-48.59] versus 42.39 [95% CI 41.05-43.73]; P < 0.01). The mean MCS score among patients on biologic therapy was also significantly higher than that of patients on oral therapy (52.46 [95% CI 50.51-54.41] versus 50.19 [95% CI 49.00-51.38]; P < 0.05). Based on adjusted multiple linear regression, biologic therapy was associated with a significantly greater increase in measures of physical functioning (P < 0.05) and mental functioning (P < 0.001) as compared to oral therapy. In conclusion, clinicians need to account for physical and mental health when making treatment decisions. Biologic therapy is associated with significantly greater increases in measures of physical and mental functioning when compared to oral therapy in the US adult psoriasis population.

Economic burden of cutaneous infections in children and adults with atopic dermatitis.

BACKGROUND/OBJECTIVES: Atopic dermatitis (AD) is a chronic, inflammatory disease affecting both children and adults. AD is associated with multiple comorbidities and complications. In particular, AD patients are susceptible to developing cutaneous infections. Studies show that comorbidities have contributed significantly to increased health care utilization and costs in AD. However, evidence regarding the degree to which this increased health care utilization and expenditure in AD is attributable to cutaneous infections is lacking. The aim of this study was to assess the impact of skin infections on health care utilization and expenditures among patients with atopic dermatitis. METHODS: This cross-sectional study examined health care utilization and expenditures for AD patients of all ages with and without skin infections in the United States using the nationally representative 1996-2015 Medical Expenditure Panel Survey (MEPS) data. RESULTS: In this study, a total of 4 825 668 (weighted) patients had a diagnosis of AD (mean age 5.7). Of these, 776 753 patients (16%) experienced skin infections (mean age 4.4). Compared to AD patients without skin infections, those with skin infections had more frequent visits to ambulatory clinics (P = 0.001) and the emergency department (P = 0.011), and increased hospitalization (P = 0.010), after adjustments for demographic and clinical factors. AD patients with skin infections were also given 3.3 more prescriptions (P < 0.0001). AD patients with skin infections incurred significantly greater health care costs, which included an additional $351/patient/year for ambulatory visits (P < 0.0001) and an additional $177/patient/year for prescription medications (P < 0.0001). CONCLUSIONS: Atopic dermatitis patients with cutaneous infections incurred significantly greater health care utilization and expenditures than those without cutaneous infections.

Comparison of mental health outcomes among adults with psoriasis on biologic versus oral therapies: a population-based study.

PURPOSE: We sought to compare the impact of biologic versus oral therapies on mental health outcomes among adult U.S. residents with moderate-to-severe psoriasis. METHODS: We performed a nationwide, cross-sectional study comparing 2,303,534 (weighted) adults with moderate-to-severe psoriasis on biologic versus oral therapies and their associated mental health outcomes using the 2003-2015 Medical Expenditure Panel Survey (MEPS). Mental health outcomes were measured with the Kessler 6 (K6), a validated measure of psychological distress, and Patient Health Questionnaire 2 (PHQ2), a screening tool for depression. RESULTS: The mean K6 score for residents on biologic therapies was significantly lower than that of residents on oral therapies (2.72 [95% CI: 2.27-3.17] versus 3.70 [95% CI: 3.27-4.12]; p < .001). The mean PHQ2 score for residents on biologic therapies was also significantly lower than that of residents on oral therapies (0.540 [95% CI: 0.390-0.690] versus 0.890 [95% CI: 0.749-1.031]; p < .001). Based on adjusted multivariable linear regression models, biologic therapy was associated with significant reductions in K6 (p < .001) and PHQ2 (p = .016) scores compared to oral therapy. CONCLUSIONS: Therapeutic choices for psoriasis impact mental health outcomes. Biologic therapy is associated with reductions in psychological distress and depression as compared to oral therapy in the U.S. adult moderate-to-severe psoriasis population.

Quality of life among dermatology patients: a systematic review of investigations using qualitative methods.

INTRODUCTION: Quality of life may be assessed using quantitative or qualitative methods. Quantitative methods are commonly used in research settings; however, they may fail to capture the full range of patient experiences and impact on quality of life. Qualitative methods may be used to address this limitation. In this systematic review, we aim to synthesize data from articles utilizing qualitative methods to assess quality of life in dermatology patients. EVIDENCE ACQUISITION: We performed a systematic review search using the MEDLINE, EMBASE, and SCOPUS databases. The search was conducted using the following search criteria: ("Dermatology" [MeSH]) AND ("Quality of Life" [MeSH]), AND ("Qualitative Research" [MeSH]), searching literature spanning from January 1, 1946 to October 5, 2016. EVIDENCE SYNTHESIS: The systematic review of 15 articles included 533 dermatology patients. Patients expressed frustration over the unpredictability of disease symptoms and having to compensate for the subsequent limitations by altering their daily routines. Patients also reported profound helplessness due to chronic skin disease and social isolation in an effort to hide their disease. Patients noted the patient-provider relationship as a source of support and information exchange, with the goal to form easy to use treatment plans that met both physician and patient expectations. CONCLUSIONS: Qualitative assessment of patient quality of life can provide new insights into the patient experience and the impact of their skin disease. Qualitative methodology may capture meaningful information that may be overlooked by quantitative methods, and it should be included in quality of life research.

Effectiveness of Online vs In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial.

Importance: Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes. Objective: To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care. Design, Setting, and Participants: The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis. Interventions: Participants were randomized 1:1 to receive online or in-person care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The in-person group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months. Main Outcomes and Measures: The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score. Results: Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was -0.27 (95% CI, -0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was -0.05% (95% CI, -1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was -0.11 (95% CI, -0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement. Conclusions and Relevance: The online, collaborative connected-health model was as effective as in-person management in improving clinical outcomes among patients with psoriasis. Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be transformative to improving patient-centered outcomes in chronic diseases. Trial Registration: ClinicalTrials.gov Identifier: NCT02358135.

Practice and Educational Gaps in Blistering Disease.

Treatment of autoimmune patients can be challenging and rewarding. These patients often remain undiagnosed for prolonged periods of time or underdiagnosed without immunologic confirmation, resulting in significant morbidity. The most important principle in management of autoimmune bullous disease is to halt blistering activity while minimizing side effects of medications, especially those caused by corticosteroids. Judicious use of systemic steroids and steroid-sparing agents are essential tools in the management of these patients. Rituximab and intravenous immunoglobulin are playing increasingly important and earlier roles in management. Understanding of and surveillance for drug side effects are critical in long-term management.

RAC1 activation drives pathologic interactions between the epidermis and immune cells.

Interactions between the epidermis and the immune system govern epidermal tissue homeostasis. These epidermis-immune interactions are altered in the inflammatory disease psoriasis; however, the pathways that underlie this aberrant immune response are not well understood. Here, we determined that Ras-related C3 botulinum toxin substrate 1 (RAC1) is a key mediator of epidermal dysfunction. RAC1 activation was consistently elevated in psoriatic epidermis and primary psoriatic human keratinocytes (PHKCs) exposed to psoriasis-related stimuli, but not in skin from patients with basal or squamous cell carcinoma. Expression of a constitutively active form of RAC1 (RACV12) in mice resulted in the development of lesions similar to those of human psoriasis that required the presence of an intact immune system. RAC1V12-expressing mice and human psoriatic skin showed similar RAC1-dependent signaling as well as transcriptional overlap of differentially expressed epidermal and immune pathways. Coculture of PHKCs with immunocytes resulted in the upregulation of RAC1-dependent proinflammatory cytokines, an effect that was reproduced by overexpressing RAC1 in normal human keratinocytes. In keratinocytes, modulating RAC1 activity altered differentiation, proliferation, and inflammatory pathways, including STAT3, NFκB, and zinc finger protein 750 (ZNF750). Finally, RAC1 inhibition in xenografts composed of human PHKCs and immunocytes abolished psoriasiform hyperplasia and inflammation in vivo. These studies implicate RAC1 as a potential therapeutic target for psoriasis and as a key orchestrator of pathologic epidermis-immune interactions.