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

Adverse Event

Probability
of AE

AE Management

Source

Phototherapy

 

 

 

 

Excimer Laser

Mild sunburn-
like reaction

14.00%

Corticosteroid

Clinical Assessment
Arch Dermatol 2003;139:759-64,

 

Blisters

42.00%

Corticosteroid

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

 

Pain

13.00%

NSAID

Lasers in Surg & Med 2002;31:202-6

 

 

 

 

 

UVB

Itching

12.00%

OTC antihistamine

Clinical Assessment, Dermatol 2000; 200(1):17-24

 

Burns

41.00%

Corticosteroid

J Eur Acad Dermatol Venereol 2000 14:S259-60

 

 

 

 

 

PUVA

Itching

13.00%

OTC antihistamine

PDR 2003, Dermatol 2000;200(1):17-24

 

Burns

80.00%

Corticosteroid

J Am Acad Dermatol 1991:25:682-4,

 

Nausea

10.00%

Pepto-Bismol®

Arch Dermatol 2003;139:325-328,

 

SCC

0.00%

Dermatologic treatment

Dermatol Surg 2001 Nov;27(11):955-9,

 

Melanoma

0.00%

Dermatologic treatment

J Am Acad Dermatol 1998:39(5 Pt 1):698-703,

Topical Therapy

Calcipotriene + Corticosteroid

Hypercalcemia

100.00%

All tested and monitored

BJD 2001;144(suppl58): 21-5,

 

Skin infection

3.00%

Antibiotic

Dermatol Online J 9(1):2,

 

Pruritus

4.90%

OTC antihistamine

BJD 2001;144(suppl58): 21-5,

 

Folliculitis

0.50%

Antibiotic

J Am Acad Dermatol 2003;48(1):48-54

 

 

 

 

 

ICI

None

None

Treatment cessation, therapeutic switch

Clinical Assessments

 

 

 

 

 

Anthralin + Corticosteroid

None

None

None

Clinical Assessments

 

 

 

 

 

Tazarotene + Corticosteroid

Pruritus

32.00%

OTC antihistamine

Clinical Assessments
Clin Ther 2000;22(10):1225-38

NSAID = non-steroidal anti-inflammatory drug, UVB = ultraviolet B phototherapy, OTC = over the counter, PUVA = psoralen + ultraviolet A (UVA) phototherapy, SCC = squamous cell carcinoma, ICI = intralesional corticosteroid injection.

 


Table 7     Adverse Event Management Costs and Data Sources

 

Adverse Event

Management

Cost

Source of Cost Data

Folliculitis

Antibiotic

$     15.00

Clinical Assessment, Redbook 2003

Skin infection

Antibiotic

$     25.00

Clinical Assessment, Redbook 2003

Hypercalcemia

Testing

$       7.31

Clinical Assessment, CMS 2003

Pruritus

OTC antihistamine

$       5.00

Clinical Assessment, Redbook 2003

Itching

OTC antihistamine

$       5.00

Clinical Assessment, Redbook 2003

Burn

Corticosteroid

$       5.10

Clinical Assessment, Redbook 2003

Blisters

Corticosteroid

$       5.10

Clinical Assessment, Redbook 2003

Nausea

Pepto-Bismol®

$       2.14

Clinical Assessment, Redbook 2003

Squamous Cell
Carcinoma

Dermatologic
treatment

$   399.81

Clinical Assessment,
Dermatol Surg 2001 Nov;27(11):955-9
($329 for inflation from 1995)

Melanoma

Dermatologic
treatment

$2,242.00

Clinical Assessment
J Am Acad Dermatol 1998 Nov;39(5 Pt 1):698-703
($1,973 adjusted for inflation)

OTC = over the counter.

 

Table 8     Total Expected Per-Patient Annual Costs
First-Line Plus Second-line Therapies

 

 

With Laser

Without Laser

 

 
Expected Cost

$2,340

$2,342

 

 

ICI = Intralesional corticosteroid injection.

 

Table 9     Expected Costs and Cost-Effectiveness

First-line Therapy Plus Only One Second-line Therapy Option*

 

Second-Line Therapy

Total Annual Expected Cost

Expected Cost / Expected TFD

Expected Cost / Expected RD

ICI

$2,035

$  35.53

$  9.65

Excimer Laser

$2,335

$  41.61

$10.73

UVB

$2,653

$  56.56

$13.10

PUVA

$2,732

$  47.37

$13.16

Anthralin + Corticosteroid

$2,034

$291.92

$9.89

Tazarotene + Corticosteroid

$2,254

$99.92

$10.92

*Assumes 100% of patients receive only one second-line therapy.  TFD = treatment-free day,
RD = remission day, ICI = intralesional corticosteroid injection, UVB = ultraviolet B phototherapy,
PUVA = psoralen + ultraviolet A phototherapy.


 Table 10     Expected Costs and Cost-Effectiveness
Stand-Alone Second-line Therapy*

 

Second-Line Therapy

Expected Cost Secondary Only

Expected Cost /
Expected TFD

Expected Cost /
Expected RD

ICI

$1,206

$  3.75

$  5.16

Excimer Laser

$2,855

$9.36

$10.56

UVB

$4,607

$17.94

$24.31

PUVA

$4,935

$16.89

$24.70

Anthralin+Corticosteroid

$1,228

$34.58

$  5.90

Tazarotene+Corticosteroid

$2,429

$20.01

$11.38

*Each therapy represents a separate model.  TFD = treatment-free day, RD = remission day,
ICI = intralesional corticosteroid injection, UVB = ultraviolet B phototherapy, PUVA = psoralen +
ultraviolet A phototherapy.

 


Table 11     Expected Costs and Cost-Effectiveness

Success Branches For Second-Line Therapy Only (100% Success)†

 

Second-Line Therapy

Expected Cost

Expected Cost /
Expected TFD

Expected Cost /
Expected RD

ICI

$   591.53

$  1.65

$  2.23

Excimer Laser

$2,280.56

$  6.51

$  7.21

UVB

$4,805.90

$16.50

$22.01

PUVA

$4,861

$15.58

$21.85

Anthralin+Corticosteroid

$   838.78

                NA

$  3.72

Tazarotene+Corticosteroid

$2,053.26

$25.01

$  8.24

†Each therapy represents a separate model.  TFD = treatment-free day, RD = remission day,
ICI = intralesional corticosteroid injection, UVB = ultraviolet B phototherapy, PUVA = psoralen +
ultraviolet A phototherapy.