Table 1     Benefits and Limitations of Comparative Second-Line Therapies

Treatment

Category

Benefits

Limitations

 

Corticosteroid

Topical

Fast acting, inexpensive

Skin thinning, bruising, stretching, redness; accentuates blood vessels; acne; internal absorption; and rarely, high blood pressure; diabetes; muscle problems; pregnancy/nursing cautions; rebound, tachyphalaxis

Calciotriene

Topical vitamin D3 analog

Safer than steroids, best for flattening lesions/removing scales, ointment slightly more effective than cream

Slower acting than superpotent topical corticosteroids; sometimes cause irritation; best used with corticosteroid; should not be used with products containing salicylic acid

Tazarotene

Topical vitamin A derivative

Improvement tends to persist

 

Slower acting than superpotent topical corticosteroids; frequent perilesional irritation; best used with corticosteroid;   pregnancy restrictions/warnings

Anthralin

Topical

Inexpensive, moderately effective

Skin irritation; skin, clothing, linen, and bathroom staining

UVB

UVB light

Broad coverage; best for thin plaques;

Slower acting; pre-response exacerbation; prolonged treatment schedules; many sessions

PUVA

Photochemo-therapy (UVA light + psoralen sensitized)

Broad coverage; more severe disease; long remissions

Itching; burning; premature skin aging; increased skin cancer risk (squamous cell carcinoma and basal cell carcinoma, melanoma); cataracts; patients must wear UVA-blocking PUVA glasses for at least 12 hours after treatment if in sunshines; prolonged treatment schedules

Excimer Laser

Light

Fast-acting; fewer treatments

Skin redness, burning, bruising;

 

Table 2     Clinical Effectiveness and Duration

 

Therapy

Probability of
Successful
Treatment

Duration of
Success
(ie Remission)

Source

Phototherapy

Excimer Laser

72.00%

20 weeks
(5 mo)

Clinical Assessments
Feldman, et al. J Am Acad Dermatol 2002;46:900-6
Trehan & Taylor. J Am Acad Dermatol 2002; 47:701-8

UVB

62.50%

12 weeks
(3 mo)*

Lest & Boer BJD 1989;120:665-70
Koo & Lebwohl, J Am Acad Dermatol Jul 1999; 41:51-9

PUVA

80.00%

22 weeks
(5.5 mo)*

Clinical Assessments
Lauharanta, BJD, 1981; 104(3):325-32
Koo & Lebwohl, J Am Acad Dermatol Jul 1999; 41:51-9

Topical Therapy

Calcipotriene +
Corticosteroid

77.00%

9 weeks
(2.25 mo)*

Ruzicka & Lorenz. BJD 1998; 138(2): 254-58
Lebwohl, et al. J Am Acad Dermatol 1998;39(3);447-50

ICI

75.00%

16 weeks
(4 mo)

Clinical Assessments

Anthralin +
Corticosteroid

81.00%

13 weeks
(3.25 mo)*

Koo & Lebwohl, J Am Acad Dermatol Jul 1999; 41:51-9

Tazarotene +
Corticosteroid

65.00%

13 weeks
(3.25 mo)*

Lebwohl, et al. BJD 2001; 40(1): 64-6

*Remission with maintenance.  UVB = ultraviolet B phototherapy, PUVA = psoralen + ultraviolet A (UVA) phototherapy, ICI = intralesional corticosteroid injection.

 

 

Table 3     Treatment Regimens and Data Sources

 

Therapy

Treatment
Regimen

Maintenance
Regimen

Source

Phototherapy

Excimer Laser

3 weeks

20 weeks

Clinical Assessments

 

2/week

None

Feldman, et al. J Am Acad Dermatol 2002;46:900-6

 

 

 

Trehan & Taylor. J Am Acad Dermatol 2002; 47:701-8

 

 

 

 

UVB

8 weeks

12 weeks

Lest & Boer BJD 1989; 120:665-70

 

3/week

1/3 weeks

Koo & Lebwohl, J Am Acad Dermatol Jul 1999; 41:51-9

 

 

 

 

PUVA

14 weeks

22 weeks

Clinical Assessments

 

2/week

1/3weeks

Lauharanta, BJD, 1981; 104(3):325-32

 

 

 

Koo & Lebwohl, J Am Acad Dermatol Jul 1999; 41:51-9

Topical Therapy

Calcipotriene +
Corticosteroid

Weeks 1-2:
CAL bid

Weekday:
CAL bid

Clinical Assessments

 

Weeks 3-6:
CAL qd

Cort qd

Weekend:
Cort bid

Ruzicka & Lorenz. BJD 1998; 138(2): 254-58

 

 

10 weeks

Lebwohl, et al. J Am Acad Dermatol 1998;39(3);447-50

 

 

 

 

ICI

1 injection
Every 3-4 wks

16 weeks
None

Clinical Assessments

 

 

 

 

Anthralin +
Corticosteroid

8 weeks
Anthralin, qd
Cort, bid wkend

13 weeks
Anthralin, qd
Cort, bid wkend

Clinical Assessments

Koo & Lebwohl, J Am Acad Dermatol Jul 1999; 41:51-9

 

 

 

 

Tazarotene +
Corticosteroid

Wk1-2
TAZ qd am
Cort, qd pm
Wk3-4
TAZ qd am
Cort 3/week pm
Wk5-6
TAZ 3/week am
Cort 2/week pm

13 weeks
TAZ  3/week am
Cort  2/week pm

Clinical Assessments

Lebwohl, et al. IJD 2001; 40(1): 64-6

ICI = intralesional corticosteroid injection, UVB = ultraviolet B phototherapy, PUVA = psoralen +
ultraviolet A phototherapy, CAL = calcipotriene, Cort = corticosteroid, TAZ = tazarotene.

 

 

 

Table 4     Healthcare Resources, Costs, and Data Sources

 

Therapy

Cost / Gram

Cost / Phototherapy
Treatment

Cost / Treatment
Regimen

Source

Calcipotriene + Corticosteroid
(betamethasone)

$    1.70

$    0.17

$   249.90

Redbook, 2003

ICI (triamcinolone acetonide)

$    2.09

(cost/ml)

--

$   106.43

Redbook, 2003

Excimer Laser

 

$151.56

$909.36

CMS, 2003

UVB

--

$  58.86

$1,412.64

CMS, 2003

PUVA (UVA +
methoxsalen capsules)

$677.00

$  67.69

$2,464.00

Redbook, 2003
CMS, 2003

Anthralin + Corticosteroid
(clobetasol)

$    0.80

$    0.96

$     50.24

Redbook, 2003

Tazarotene + Corticosteroid
(clobetasol)

$    2.60

$    0.96

$   278.60

Redbook, 2003

ICI = intralesional corticosteroid injection,
UVB = ultraviolet B phototherapy, PUVA = psoralen + ultraviolet A (UVA) phototherapy.

Table 5     Physician Resources, Costs, and Data Sources

 

Therapy

Office Visits
During
Treatment

Office Visits
During
Remission

Total Office Visit
Cost / Treatment Cycle

Source

Calcipotriene + Corticosteroid
(betamethasone)

2

0

$143.83

Clinical Assessments
CMS, 2003

ICI (triamcinolone acetonide)

2

0

$143.83

Clinical Assessments
CMS, 2003

Excimer Laser

1

0

$  92.70

Clinical Assessments
CMS, 2003

UVB

3

0

$194.96

Clinical Assessments
CMS, 2003

PUVA (UVA +
methoxsalen capsules)

4

0

$246.09

Clinical Assessments
CMS, 2003

Anthralin + Corticosteroid
(clobetasol)

3

0

$194.96

Redbook, 2003

Tazarotene + Corticosteroid
(clobetasol)

2

0

$143.83

Clinical Assessments
CMS, 2003

Other Cost Components and Sources

Initial Physician Visit

 

 

$  92.70

CMS, 2003*

Follow-up Physician Visit

 

 

$  51.13

CMS, 2003*

*Center for Medicare and Medicaid Services, 2003 National Physician Fee Schedule Relative Value File
(CPT 99203 & 99213).  ICI = intralesional corticosteroid injection, UVB = ultraviolet B phototherapy,
PUVA = psoralen + ultraviolet A (UVA) phototherapy.

 Table 6     Adverse Treatment Reactions and Data Sources

 

Therapy