US Perspectives in the Management of Psoriasis and Psoriatic Arthritis: Patient and Physician Results from the Population-Based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) Survey

Psoriasis affects more than 7 million adults in the USA [1]. While the prevalence of psoriasis has remained generally stable at approximately 3 % over the past decade [1, 2], the incidence nearly doubled between 1970 and 2000 [3]. Patients with psoriasis report a significant impact on their quality of life, including mental and social function [4‐6]. In addition, approximately 30 % of psoriasis patients also develop psoriatic arthritis (PsA) [7‐9], which can add to the impact on quality of life, affecting physical function and leading to productivity loss and disability [4, 5, 10, 11]. Because of the chronic, inflammatory nature of psoriasis and PsA, long-term systemic therapy is often necessary to control the signs and symptoms, and to improve physical function and quality of life for patients [7, 12]. Recent reports have identified undertreatment and treatment dissatisfaction as significant barriers to optimal care of psoriasis and PsA patients [9, 13].

The population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey of 3426 patients and 781 dermatologists and rheumatologists in North America and Europe was designed to evaluate the diagnosis and ongoing management of patients with psoriasis and PsA from the patient and physician perspectives, as well as evaluating unmet treatment needs. The large volumes of data collected from the study were too extensive to include in a single publication. Results from the global patient and physician MAPP surveys, including the US patient findings, have been published separately [14‐16]. In this report, we explore findings from all US participants, including patients, dermatologists, and rheumatologists, to further investigate similarities and differences in attitudes toward disease severity and treatment, and to identify opportunities to improve the care of patients with psoriasis and PsA.

Abt SRBI, Inc. (New York, NY, USA) conducted the MAPP survey between June and August 2012. The study methodology has been reported previously [14, 16]. Briefly, this systematic household telephone survey used random digit dialing to identify a probability sample. Household members aged 18 years or older could participate if they had ever been diagnosed with psoriasis or PsA. Patients did not have to be under the care of a healthcare provider (HCP) at the time of the survey.

Dermatologists and rheumatologists were identified through the American Medical Association/American Osteopathic Association national database and were contacted through random sampling methods. Dermatologists were screened to ensure that 50 % or more of their practice was devoted to medical dermatology.

MAPP was unique in its design as a large-scale, multinational, population-based survey that included patients with psoriasis and/or PsA, as well as physicians. The results of the current report reflect the findings from the US respondents, including patients, dermatologists, and rheumatologists, with a goal of identifying the similarities and discrepancies in patient and physician responses, as well as the challenges and unmet needs of diagnosis, assessment, and treatment.

To participate in the MAPP survey, patients were not required to be under the care of a physician, receiving treatment, or a member of a patient organization. A substantial proportion of patients who participated had not seen an HCP for their psoriasis within the previous 12 months. The reported reasons included that they did not feel an HCP could help, demonstrating frustration with the current management options. This was mirrored by approximately half of the dermatologists and one third of the rheumatologists, who agreed that they were concerned about patients leaving their practice because of frustration or dissatisfaction with currently available therapies. Of those patients who had seen an HCP within the previous 12 months, approximately 30 % of both psoriasis and PsA patients saw a primary care physician, not a specialist, which is slightly higher than the rate of 22 % recently reported by the National Psoriasis Foundation (NPF) [17].

When asked about factors that affect disease severity, patient and physician responses differed. Patients, especially those with psoriasis, consistently placed more emphasis on pruritus than did physicians. US psoriasis patients [15] and global psoriasis patients [14] reported itching as the most important factor contributing to disease severity, followed by the location and size of lesions. In contrast, just over 10 % of US dermatologists cited itching as the most important factor. This finding may be related to the fact that itching is not currently captured in most physician assessments or in the most commonly used psoriasis assessment tools, including those used in clinical trials but not often in practice, such as the Psoriasis Area and Severity Index and the physician’s global assessment of disease severity [18]. Even among PsA patients, itching was cited by nearly 15 % of patients as the most important factor contributing to disease severity. Overall, these findings suggest that patients may assess disease severity differently from physicians, and tend to consider symptoms beyond those usually assessed in a physician visit. Improved communication between patients and physicians may help to foster the understanding of all aspects of disease that impact patient quality of life.

Joint pain was reported by more than half of the patients with a diagnosis of psoriasis alone. However, fewer than 20 % of dermatologists reported that their psoriasis patients had joint pain. Although more than three quarters of both dermatologists and rheumatologists agreed that PsA may go undiagnosed because of failure to connect skin and joint symptoms, fewer than 60 % of dermatologists discussed this risk with all of their psoriasis patients. A separate report recently highlighted the underdiagnosis of PsA in dermatology treatment centers, where approximately 40 % of patients diagnosed with PsA by a rheumatologist had not been diagnosed by their dermatologist [9].

The MAPP survey included additional questions about managing PsA patients that may provide more insights into the potential underdiagnosis of this disease. More than one third of the surveyed US dermatologists reported that the greatest challenge in managing their PsA patients was differentiating PsA from other arthritic diseases. However, fewer than 10 % felt they would need to refer to or involve other specialists in the care of their PsA patients. The surveyed US rheumatologists reported delayed referrals as the second most common challenge in treating PsA patients. Fewer than 40 % of physicians reported co-management of PsA patients. Most often, this relationship consisted of a rheumatologist primarily being responsible for prescribing decisions and a dermatologist monitoring skin symptoms. A recent review and meta-analysis provided recommendations for dermatologists regarding screening, diagnosing, and treating PsA patients [19]. Educating dermatologists to routinely discuss and evaluate joint disease with their psoriasis patients—and providing guidance on when to refer them to a rheumatologist—may bring about more timely diagnosis and treatment of patients with PsA. Co-management and/or collaborative efforts among dermatologists and rheumatologists may ensure that psoriasis patients, while receiving care for their skin disease, are also adequately screened and further assessed for the presence of PsA.

Despite expanding therapeutic options for managing psoriasis and PsA patients, undertreatment remains a challenge [9, 13]. Although approximately 70 % rated their disease as moderate or severe [15], US patients participating in the MAPP survey reported low treatment rates, with only about 10 % of psoriasis patients reporting treatment with conventional oral or biologic therapy. US dermatologists reported nearly three times greater current use of conventional oral therapies and more than seven times greater current use of biologic agents for their psoriasis patients than were reported by the surveyed US patients. Likewise, while dermatologists and rheumatologists reported systemic therapy use in the majority of PsA patients, only half of the PsA patients reported current use of oral or biologic therapy. There are several possible explanations for these discrepancies. Patients included in the MAPP survey were not required to be seeing an HCP or receiving treatment at the time of the survey, and patients and physicians were not matched. Patients may have been seeing another specialist or a primary care physician for their disease. It is possible that seeing a primary care physician rather than a physician specializing in dermatologic or rheumatic conditions contributed to the lower treatment rates reported by the patients than by the participating physicians. In addition, approximately 20 % of psoriasis patients reported having no skin lesions as reasons for not seeing an HCP, suggesting that treatment would not be required. However, although higher rates of treatment were reported by physicians than by patients, physicians indicated that more than 30 % of patients were still not receiving systemic therapy for their moderate to severe psoriasis or for PsA at the time of the survey, in contrast to guideline recommendations [20, 21]. In addition, other surveys have also shown a high level of undertreatment. In the 2011 NPF survey, up to one third of patients were not receiving treatment for their moderate or severe psoriasis, and of the patients who were receiving treatment, an estimated 20–30 % were receiving topical monotherapy [13].

The complexity and time-consuming nature of treating patients with psoriasis and PsA may contribute to undertreatment. Most dermatologists reported that managing their psoriasis patients takes up more of their time than managing other patients, and approximately one third of dermatologists and rheumatologists described the care of patients with PsA as complicated and time consuming. Comorbidities, which were reported by the majority of patients, may also be a contributing factor to the complexity of treating psoriasis and PsA patients. In addition, multiple physicians providing care to an individual patient may lead to miscommunication or confusion over roles in prescribing decisions, and may contribute to lower treatment rates, emphasizing the importance of communication among HCPs.

Dissatisfaction with current therapies may impact disease management and treatment. The most commonly cited barriers to use of conventional oral therapy, across patients, dermatologists, and rheumatologists, were concerns with long-term safety and tolerability, and lack of effectiveness. Patients also reported laboratory monitoring (16.4 %) and lifestyle modification (7.0 %) as being among the top three reasons contributing to the burden of these therapies. Opinions on the barriers to use of biologic therapy differed among patients and physicians. Patients reported anxiety about and preparation of injections as the most common reasons for therapy being burdensome, and concerns with safety and tolerability or lack of effectiveness as reasons for discontinuation, while dermatologists and rheumatologists cited lack of long-term safety and cost as the most common reasons for not initiating or continuing biologic therapy. The discrepancy in the importance of cost to patients and physicians may reflect the effort required to determine insurance eligibility and ensure reimbursement before prescribing, which falls heavily on physicians versus patients, thus cost may not be considered an issue by patients. The reasons for treatment discontinuation are generally consistent with those found in a report of 1095 patients with moderate to severe psoriasis treated in dermatology clinics within the USA [22]. A survey of NPF members also found a high rate of dissatisfaction with treatment among psoriasis patients (52.3 %) and PsA patients (45.5 %), and cited adverse effects and efficacy as the main reasons for patient discontinuation of biologic therapy, along with inadequate insurance coverage and cost [13].

Overall, the results of the MAPP survey among the US respondents were consistent with those of global respondents; however, some differences among physicians and patients were noted. For patients with moderate to severe psoriasis, a higher proportion of US dermatologists reported treating patients with biologic therapies, compared with dermatologists globally (35.8 versus 19.6 %, respectively) [16]. Likewise, higher proportions of US dermatologists and rheumatologists reported treating PsA patients with biologic therapies, compared with dermatologists and rheumatologists globally (46.9–52.7 versus 30.6–33.4 %) [16]. The challenges of managing psoriasis and PsA patients identified by US physicians and global physicians were similar; however, affordability of therapies was considered a treatment challenge for psoriasis and PsA by a greater proportion of US physicians than global physicians (28.7–57.4 % for US physicians versus 22.0–36.1 % for global physicians) [16]. Survey responses among US patients generally reflected those of the global population. Differences between US patient responses and global patient responses to the MAPP survey have been reviewed previously; these include a higher proportion of US patients than global patients reporting comorbidities such as arthritis (48.3 versus 34.4 %) and hypertension (42.8 versus 32.7 %) [14, 15]. Treatment patterns reported by US and global patients were generally similar, as were the reasons identified for treatment discontinuation or for not initiating treatments.

The findings from the MAPP survey are limited by survey-related factors, which include lack of a control group and reliance on accurate recall and interpretation of questions. Because the survey was blinded, respondents could not be contacted again to follow up or clarify answers. Although patients and physician results are compared within this report, the patients and physicians were not matched, and the survey was not designed to directly compare specific disease or treatment differences.

The findings from the US MAPP survey population highlight the differences in perceptions between physicians and patients with psoriasis and/or PsA regarding disease severity and the impact on treatment choices. Patients with psoriasis consistently reported that itching, which is usually not captured in current assessment tools, is the most influential factor in determining psoriasis severity, whereas physicians reported the size or location of lesions as leading factors contributing to disease severity. Psoriasis patients should be screened and assessed routinely for symptoms of PsA, and dermatologists need tools to differentiate PsA from other rheumatic diseases. These enhancements, along with improving referral rates and collaboration between dermatologists and rheumatologists, may lead to improved treatment of psoriasis and PsA. Ongoing communication between patients and physicians is needed for better understanding of perceptions of disease severity, discussion and agreement on treatment options, and establishment of realistic treatment goals. The need for safe, effective, and easy-to-use therapies for both psoriasis and PsA remains.