D. de Hoop

Patient Compliance and Disease Management in the Treatment of Psoriasis in the Netherlands

Background: Compliance behaviour and disease management are important issues in chronic skin diseases. Psoriasis patients are ‘experts by experience’ because of many years of treatment. Therefore, it is relevant to gather data from patients on the actual use of antipsoriatic treatments. Objective: The following questions are addressed: (1) What is the present mode of prescription and actual use of antipsoriatic treatments, including topical treatments, photo(chemo)therapy and systemic treatments? (2) What information do patients expect from their doctor, and do they actually receive this information. Methods: To answer these questions, a questionnaire survey was mailed to the subscribers of Psoriasis, the journal of the Dutch Psoriasis Patients’ Organisation. Results: (1) Major issues in the treatment of psoriasis are (a) long-term management, (b) control of mild, moderate but also extensive psoriasis and (c) control of psoriasis on difficult localisations. Patients perceive itch, scaliness and visibility as major criteria for efficacy. (2) Topical treatment is the mainstay in the management of psoriasis. Calcipotriol is the most prescribed drug. Photo(chemo)therapy has an intermediate position between topical and systemic treatments. UVB is prescribed more than twice as frequently as PUVA and 10% of the patients on photo(chemo)therapy proved to be treated with UVB at home. Only 16% of the patients were on a systemic treatment; methotrexate and acitretin were the most frequently used systemic treatments. (3) More than 70% of the patients indicated that they had taken part in the selection of a treatment. In general, the patients were satisfied about the contact with their dermatologist and general practitioner. Compliance with the duration of treatment is limited, especially with regard to topical treatment. Patient compliance with the dose of the treatment is better. Again compliance is the worst in topical treatments. (4) Patients have a strong preference for an effective treatment which is safe for long-term use. Only a minority of patients wants a fast clearing treatment. Conclusion: Itch, scaliness and visibility provide the most relevant information on the severity of psoriasis, as the patients perceive themselves. Treatment duration is often unrestricted, especially with regard to topical treatments, which implies that the cumulative toxicity potential of these treatments may have a serious impact on their safety profile. Patients regard it of importance to have a vote in the selection of the treatment and regard safety as more important than fast clearing.

Scalp Psoriasis, Clinical Presentations and Therapeutic Management

Background: The scalp is a well-known predilection site for psoriasis. Many patients indicate that scalp psoriasis is both psychologically and socially distressing. Objective: The aim of the present investigation is to provide epidemiological data on the various manifestations of scalp psoriasis, as well as on its therapeutic management. Methods: A questionnaire, targeted on scalp psoriasis, was mailed to patient subscribers of a Dutch journal on psoriasis. In total 1,023 forms were returned and evaluated. Results: Remarkably, a relatively high occurrence of facial psoriasis (25%) and nail psoriasis (40%) was recorded. The dynamics of scalp psoriasis were rather similar to psoriasis at other sites with respect to the total duration of the disease and exacerbations/remissions. In 57% of the patients, psoriasis was psychologically and socially distressing, at least occasionally. Itch and scaling proved to be the leading symptoms, in terms of frequency of occurrence as well as in terms of distress. Therefore, these parameters should be regarded as primary efficacy criteria in the treatment of scalp psoriasis. On average, most patients were seen by the dermatologist 5 times a year. The majority of prescriptions (76%) was given by the dermatologist. The application of topical corticosteroids was by far the most frequent treatment modality. To our surprise, calcipotriol was used by 28% of patients. At the time of investigation calcipotriol was only available as ointment. Tar shampoos were used by 51% of the patients, although the clinical efficacy of such a shampoo has never been demonstrated in a controlled study. A remarkable observation was the lack of instruction on the duration of treatment and the frequency of applications. In fact, 72% of the patients used topical treatments, including topical corticosteroids, for more than 8 weeks, and 42% of the patients used an intermittent schedule of a few applications per week. Conclusions: Based on the present survey, the following profile for an optimal treatment of scalp psoriasis can be constructed: (1) effective applications a few times per week; (2) either a lotion or an emulsion, and (3) safety for long-term use.

Induction of eruptive benign melanocytic naevi by immune suppressive agents, including biologicals.

Background  Eruptive naevi have been described to potentially arise in immune compromised patients.

Pharmacoeconomic Evaluation of Calcipotriol (Daivonex®/Dovonex®) and UVB Phototherapy in the Treatment of Psoriasis: A Markov Model for The Netherlands

Background: The high prevalence and chronic nature of psoriasis leads to high costs in relation to the treatment and control of the disease. A number of clinical trials have shown that a combination therapy of calcipotriol cream (Daivonex®/Dovonex®, Leo Pharmaceutical Products) and ultraviolet B phototherapy (UVB) decreases the total number of UVB exposures required compared to UVB treatment alone. From a societal point of view, the addition of calcipotriol to UVB therapy could achieve cost savings due to the fewer UVB treatments needed and the reduced travelling and time off work for patients. Fewer UVB exposures may also have other beneficial effects, i.e., shortened waiting lists and less risk to patients of developing cancer or photoaging of the skin. Objective: To compare the cost-effectiveness of treating psoriatic patients in the Netherlands with calcipotriol cream used daily combined with twice weekly UVB treatments to emollient used daily combined with UVB given 3 times weekly. Methods: Based on the clinical results from a Canadian trial, a decision-analytical model was constructed to simulate treatment outcomes and estimate the costs of managing psoriatic patients in the Netherlands over a period of 20 weeks from initiation of therapy. Unit costs and details of standard treatment protocols were collected from Dutch dermatology centres in hospitals and the community for use in the model. Other therapies, such as topical corticosteroids, tar or dithranol were not investigated in this analysis. Results: The total cost of managing psoriatic patients in the Netherlands over a 20-week period is estimated as EUR 1,175.90 for those treated with calcipotriol and UVB and EUR 1,212.14 for patients treated with emollient and UVB. Thus, the former treatment, adding calcipotriol to UVB phototherapy, provides a minor cost saving of EUR 36.24 (3%) compared to the cost of UVB treatment alone. Sensitivity analyses demonstrated that these results are sensitive to changes in the cost of UVB treatment. Conclusion: Calcipotriol treatment combined with UVB phototherapy is a cost-neutral alternative to UVB phototherapy used with an emollient. The patients achieve treatment success in the same time on both treatments but the former, with calcipotriol, requires less exposure to UVB radiation. The additional drug costs from using calcipotriol are offset by savings from the fewer UVB sessions required. Essential beneficial effects for patients are less inconvenience, less risk of developing photoaging of the skin and less exposure to potentially carcinogenic radiations.

A generalized skin eruption in a human immunodeficiency virus–infected boy

Editor Epidermodysplasia verruciformis (EV) is a rare disorder characterized by widespread human papillomavirus (HPV) infection and malignant transformation. We report a young patient with EV who has a severe compromised cell-mediated immunity due to human immunodeficiency virus (HIV). A 15-year-old African boy, adopted by relatives at the age of 2, was tested as HIV positive. His biological mother died of AIDS 13 years previously, and it was assumed that he was infected perinatally. His past medical history did not reveal any health problems or illnesses. Physical examination showed a widespread skin eruption of fleshcoloured and hypopigmented flat-topped papules (1–5 mm) first noticed at least 2 years before (fig. 1). Laboratory results indicated a severe compromised cell-mediated immunity (CD3 number 0.71 × 10/L [normal 0.8–3.5 × 10/L], CD4 number 0.02 × 10/L [normal 0.4–2.1 × 10/L]). Histological examination of a skin biopsy (fig. 2) showed acanthosis with hyperorthokeratosis, an irregular granular layer and perinuclear halos with associated blue-grey pallor of the cytoplasma consistent with EV. Using a broad-spectrum PCR-reverse hybridization assay for the detection and identification of all known HPV genotypes from the beta-papillomavirus genus, HPV 5 was detected in the biopsy specimen. EV is most commonly described as an autosomal recessive disorder, which usually begins during early childhood and is characterized by skin eruptions of flat-to-papillomatous, wart-like papules and reddish brown pigmented macules, which may remain unchanged for many years. The disease results from an abnormal susceptibility to a specific group of HPV genotypes. HPV 5 is the most frequently found EV HPV genotype and is associated with malignant conversion. Only a few cases of EV-like eruption have been described in association with HIV infection. Cellular immunodeficiency predisposes patients with HIV infection to cutaneous HPV infection. Treatments for common warts seem to offer no benefit in the therapy of EV. Retinoids with or without interferon may be beneficial, although discontinuation of this therapy often results in recurrence of the lesions. The role of highly active anti-retroviral therapy (HAART) in improving anti-HPV immunity in HIV patients is limited. Our patient has been on HAART for 12 months without any observed improvement of his skin disease, although his CD3 number raised to 1.96 × 10/L and his CD4 number to 0.44 × 10/L and his viral load decreased. It is important to bear in mind the diagnosis of EV when a patient is seen with multiple flat warts, or flesh-coloured and hypopigmented flat-topped papules, like the abovementioned patient infected with HIV. As a high incidence of malignant conversion has been recorded in patients with EV, patients should be effectively protected from sunlight and observations for malignant changes should be done.

The Herman Musaph Award for Psychodermatology

In 1995 the Herman Musaph Foundation for Psychodermatology was established in Amsterdam, the Netherlands. The Foundation commemorates Herman Musaph, psychiatrist and one of the founding fathers of psychodermatology. The primary aim of the Foundation is to promote psychodermatological research. Biennally, the Foundation presents the Herman Musaph Award to a scientist who has made an outstanding contribution to the advancement of psychodermatology. A presentation ceremony is held during each International Congress on Dermatology and Psychiatry, organized by the European Society for Dermatology and Psychiatry. The Herman Musaph Award is a Medal of Honour, made by a renowned Dutch artist, Geer Steyn. The first Award was presented to Uwe Gieler (1999), the second to Caroline Koblenzer (2001). The third Award will be presented during the 10th International Congress on Dermatology and Psychiatry, to be held in Brussels, May 8–10, 2003.