Cost-Effectiveness Analysis of Psoriasis Treatment Modalities in Malaysia

Background: There is limited evidence detailing the cost-effectiveness of psoriasis treatments in the Asian region. Therefore, this study is aimed to evaluate the cost-effectiveness of 3 psoriasis treatments tailored for moderate to severe psoriasis, namely topical and phototherapy (TP), topical and systemic (TS), and topical and biologic (TB) regimens, respectively. Methods: This has been achieved by the participation of a prospective cohort involving a total of 90 moderate to severe psoriasis patients, which has been conducted at 5 public hospitals in Malaysia. The main outcome measures have been evaluated via cost and effectiveness psoriasis area severity index (PASI)-75 and/or body surface area (BSA) <5 and/or dermatology life quality index (DLQI) ≤5), estimated from the societal perspective over a 6-months duration. All costs are based on 2015’s recorded Malaysian Ringgit (RM) currency. Results: Consequently, TS has been found to be the most cost-effective treatment with the lowest cost/PASI-75/and/or BSA <5 and/or DLQI ≤5, valued at RM9034.56 (US$2582.55). This is followed by TP, which is valued at RM28 080.71 (US$8026.93) and TB, valued at RM54 287.02 (US$15 518.06). Furthermore, one-way sensitivity analysis has highlighted the cost of medication as the most sensitive parameter. Conclusion: Thus, the input from this study is helpful for policy-makers in determining the first line treatment for moderate to severe psoriasis with consideration of the costs and its effectiveness in Malaysia. This will consequently allow hospitals to justify and provide the essential resources for further research and development, as well as the adoption of better treatment options

Doctor shopping behaviour and its predisposing factors amongst dermatology patients

Doctor shopping increases health economic burden and morbidities. Its prevalence and predisposing factors have to be identified in order to formulate preventive measures. We aimed to determine the prevalence of doctor shopping, its reasons and predisposing factors by conducting a cross sectional study of new patients at the Dermatology Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Doctor shopping was defined as having consultation with ≥3 healthcare providers without a referral for the same illness prior to the patients’ visit to UKMMC. Reasons and contributing factors were classified as disease, healthcare provider, logistic and cost related. Data was collected by a face to face interview. Dermatology Life Quality Index (DLQI) questionnaire determined disease impact on the patients. A total of 58 (55.8%) female and 46 (44.2%) male patients participated. Referral was patient-initiated in 51.9% while 40.4% were doctor shopping. Age, gender, ethnicity, income, occupation and type of health finance provider were not associated with this behaviour. About 95% doctor shopped due to disease factors: searching for a cure (95.2%), lack of improvement (88.1%), worsening disease (50.0%), dissatisfaction with treatment (31.0%), seeking other opinions (26.2%) and exploring treatment options (26.2%). Impaired DLQI (OR 1.17; 95% CI 1.08,1.38), p 0.04, and disease related factors (OR 6.57; 95% CI 1.52, 7.72), p 0.041 were significant independent risk factors. Doctor shopping is very common among our patients. Reasons and predisposing factors are predominantly disease related. Patient education and counselling is important in management of dermatological diseases to prevent doctor shopping

Progressive and persistent Increase in prevalence of methyldibromo glutaronitrile (MDBGN) contact sensitization from 2010 to 2018 in a tertiary center

BACKGROUND: Contact sensitization allergens evolves periodically. Continual surveillance is necessary in order for clinicians to focus on current trend of allergen in contact dermatitis. Methods: This is a nine-year retrospective study on patch testing using European Baseline Series done on patients between 2010 to 2018 at Dermatology Unit, UKM Medical Centre. Results: There were 787 patients total. 70% were female and 30% were male. Mean age was 45 years old. 87% (725) of patients tested positive. Majority of cases were Malays (60.4%) followed by Chinese (23.4%) and Indians (6.2%). Cumulatively over 9 year period, the leading allergens were potassium dichromate (32.7%), methyldibromo glutaronitrile (MDBGN, 31.6%), nickel sulphate (30.6%) formaldehyde (29.1%) and fragrance mix (23.1%). Since 2014, MDBGN is on the emergence and is consistently the top allergen at our centre up till now with the highest rate of test positive 51% (2017).This was constantly followed by potassium dichromate (36%, 2018) and formaldehyde (34%, 2018). Conclusion: The emergence of MDBGN as chief sensitising agent is alarming and question should be raised on strict implementation of policies upon this banned substance

A case series exploring the efficacy, secondary failure, paradoxical event & relapse with ustekinumab therapy in chronic plaque psoriasis

Ustekinumab is an anti-IL12/23 biologic agent used for treatment of psoriasis with excellent efficacy. However, there are therapeutic obstacles such as secondary failure and paradoxical event. Disease relapse upon discontinuation of therapy is common. A case series was performed on patients with chronic plaque psoriasis who received ustekinumab between 2013 to 2018 at a tertiary referral centre. Demographics, clinical characteristics, duration of therapy, efficacy, treatment complications, rate and pattern of relapses were determined from the patients’ medical records. Out of 8 patients, 6 (75%) patients were males. There were 6 (75%) biologic-naïve patients. Median age was 41.5 years (IQR26.8-48.3), median duration of psoriasis was 16.5 years (IQR6.5-23.0). Median duration to achieve Psoriasis Activity and Severity Index (PASI)75 was 16 weeks and median total duration of treatment was 102 weeks. All patients achieved treatment success. PASI75 at week 12 was achieved by 37.5%, a median of 16 weeks was required to achieve at least PASI 75 but 6 (75%) attained PASI 90 by then. One patient (12.5%) developed paradoxical event with pustular and plaques. Secondary failure occurred in 2 (25%) patients. All patients relapsed after treatment discontinuation, relapse occurred at median of 40 weeks. Most (71%) developed plaques on relapse but 25% developed plaques and pustules. All but one patient required further biological agent for treatment of relapse. Ustekinumab was efficacious in all patients. Treatment success was achieved slightly later than standard duration. The rare occurrences of secondary failure and paradoxical were observed. Relapse was inevitable, new onset pustular eruptions featured in relapses

Hints from the skin beneath: Vitiligo in Vogt–Koyanagi–Harada disease

Vogt–Koyanagi–Harada disease (VKHD) is a major vision-threatening autoimmune disease. One of its associated features is vitiligo. Little study has been done on the association between vitiligo and the disease activity of VKHD. The authors searched available literature on the relationship between vitiligo and ophthalmic disease activity in VKHD in terms of pathogenesis, clinical presentations, risk factors as well as disease activity. Among the findings is that early treatment of VKHD may be associated with full recovery. The reversal of poliosis and vitiligo is associated with the remission of uveitis, but the reverse does not hold true, whereby the worsening of vitiligo may not reflect the worsening of uveitis. It is also found that there may be an association between immunotherapy and Vogt–Koyanagi–Harada-like disease. In summary, vitiligo is an immune-mediated cutaneous manifestation which may contribute to diagnostic and treatment strategies in VKHD. Future research on genetic differences in vitiligo is still needed and may contribute to specific monitoring and therapeutic approach in this disease

Multiple concurrent primary extramammary Paget’s disease

Extramammary Paget’s disease (EMPD) is a rare malignant disorder of the skin, which was described in as early as the nineteenth century. EMPD usually occurs as a single lesion in the apocrine sweat gland–bearing skin with abundant hair follicles. Here, we present an elderly man who suffered from a non-resolving chronic genital pruritus for 8 months. Initially, he was managed for recurrent fungal infection and eczema. Later, a diagnosis of the rare condition multiple primary EMPD was made based on the histopathology findings and appropriate treatment was given

A comparison of autologous serum, plasma, and whole blood for intradermal autoreactivity testing in patients with chronic spontaneous urticarial: a cross-sectional study

Background: Autologous serum (ASST) and plasma (APST) skin testing confirm autoreactivity in chronic spontaneous urticaria (CSU). Whole blood autohemotherapy has been used. Plasma and even whole blood may be used instead of serum with relatively quicker preparation and cheaper method especially using the latter in centers with limited resources. Purpose: The purpose of the study is to determine if similar intradermal skin reactions can be observed when using either serum, plasma, or whole blood in autologous skin tests and to determine factors associated with positive tests and wheal diameter. Methods: We performed a cross-sectional study of chronic urticaria patients in a dermatology clinic. Tests were performed according to EAACI/GA2 LEN Task Force recommendations. Urticaria Activity Score over 7 days (UAS7) was assessed. Statistical analyses included Chi-square, Mann–Whitney U, Spearman’s, and Wilcoxon rank tests. Results: Twenty-six (77%) females and 8 (24%) males mean age 34 (26–42) years participated. ASST, APST and autologous whole blood for skin testing (AWBST) positivity rates were 24%, 29% and 27%, respectively (P = 0.86). 13 (38%) had at least 1 positive test; all tests were negative in 21 (62%). All tests were positive in 7 (21%), 3 (23%) were positive APST alone, 2 (15%) AWBST, 1 (8%) ASST. Pretest UAS7 was higher with those with test positive (P = 0.04). Test results were unaffected by age, gender, disease duration, atopy, anti‑nuclear antibody, and thyroid status. Wheal diameter correlated with thyroid-stimulating hormone (P = 0.04). Conclusion: Autoreactivity rates were similar with ASST, APST,and AWBST. Positive tests were associated with severe CSU. Autologous whole blood may be a simpler and less costly alternative to plasma and serum for autoreactivity skin testing in patients with chronic urticaria

Doctor shopping behaviour and its predisposing factors amongst dermatology patients

Doctor shopping increases health economic burden and morbidities. Its prevalence and predisposing factors have to be identified in order to formulate preventive measures. We aimed to determine the prevalence of doctor shopping, its reasons and predisposing factors by conducting a cross sectional study of new patients at the Dermatology Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Doctor shopping was defined as having consultation with ≥3 healthcare providers without a referral for the same illness prior to the patients’ visit to UKMMC. Reasons and contributing factors were classified as disease, healthcare provider, logistic and cost related. Data was collected by a face to face interview. Dermatology Life Quality Index (DLQI) questionnaire determined disease impact on the patients. A total of 58 (55.8%) female and 46 (44.2%) male patients participated. Referral was patient-initiated in 51.9% while 40.4% were doctor shopping. Age, gender, ethnicity, income, occupation and type of health finance provider were not associated with this behaviour. About 95% doctor shopped due to disease factors: searching for a cure (95.2%), lack of improvement (88.1%), worsening disease (50.0%), dissatisfaction with treatment (31.0%), seeking other opinions (26.2%) and exploring treatment options (26.2%). Impaired DLQI (OR 1.17; 95% CI 1.08,1.38), p 0.04, and disease related factors (OR 6.57; 95% CI 1.52, 7.72), p 0.041 were significant independent risk factors. Doctor shopping is very common among our patients. Reasons and predisposing factors are predominantly disease related. Patient education and counselling is important in management of dermatological diseases to prevent doctor shopping

A randomized, single-blind trial of clobetasol propionate 0.05% cream under silicone dressing occlusion versus intra-lesional triamcinolone for treatment of keloid

Background and Objective: Keloid is conventionally treated with intra-lesional (IL) triamcinolone, which is highly operator dependent and has its own adverse effects. Topical steroid and silicone dressings are a patient friendly and non-invasive treatment alternative. We therefore sought to determine the efficacy and safety of topical clobetasol propionate (Dermovate�) 0.05% cream under occlusion with Mepiform� silicone dressing compared to IL triamcinolone in the treatment of keloid. Methods: This was a prospective, randomised, observer-blinded study. Two keloids on the same site were randomly assigned to receive either daily topical clobetasol propionate 0.05% cream under occlusion with silicone dressing (Scar 1) or monthly IL triamcinolone injection (Scar 2). Efficacy was assessed using patient and observer scar assessment scale (POSAS) at 4-weekly intervals up to 12 weeks. Dimension of keloid and adverse effects were also assessed. Results: A total of 34 scars from 17 patients completed the study. There was significant improvement of POSAS at 12 weeks compared to baseline within each treatment group. However, there was no statistically significant difference in POSAS at 12 weeks between the two treatments. Keloid dimensions showed a similar trend of improvement by week 12 with either treatment (p = 0.002 in Scar 1, p = 0.005 for Scar 2). However, there was no significant difference between the treatment. In the IL triamcinolone group, all patients reported pain and 70.6% observed necrotic skin reaction. There was a significantly higher rate of adverse effects such as erythema (41.2 vs. 17.6%), hypopigmentation (35.3 vs. 23.5%), telangiectasia (41.2 vs.17.6%) and skin atrophy (23.5 vs. 5.9%) documented in the IL triamcinolone group when compared to clobetasol propionate 0.05% cream under occlusion with silicone dressing. Conclusion Clobetasol propionate 0.05% cream under occlusion with silicone dressing is equally effective and has fewer adverse effects compared to IL triamcinolone. Hence, it may be used as an alternative treatment for keloid particularly in patients with low pain threshold, needle phobia and those who prefers home-based treatment

A randomized,single-blind trial of clobetasol propionate 0.05% cream under silicone dressing occlusion versus intra-lesional triamcinolone for treatment of keloid

Background and objective keloid is conventionally treated with intra-lesional (IL) triamcinolone, which is highly operator dependent and has its own adverse effects. Topical steroid and silicone dressings are a patient-friendly and non-invasive treatment alternative. We, therefore, sought to determine the efficacy and safety of topical clobetasol propionate (Dermovate) 0.05% cream under occlusion with Mepiform silicone dressing compared to IL triamcinolone in the treatment of keloid. Methods This was a prospective, randomised, observer-blinded study. Two keloids on the same site were randomly assigned to receive either daily topical clobetasol propionate 0.05% cream under occlusion with silicone dressing (Scar 1) or monthly IL triamcinolone injection (Scar 2). Efficacy was assessed using patient and observer scar assessment scale (POSAS) at 4-weekly intervals up to 12 weeks. Dimension of keloid and adverse effects were also assessed. Results A total of 34 scars from 17 patients completed the study. There was significant improvement of POSAS at 12 weeks compared to baseline within each treatment group. However, there was no statistically significant difference in POSAS at 12 weeks between the two treatments. Keloid dimensions showed a similar trend of improvement by week 12 with either treatment (p = 0.002 in Scar 1, p = 0.005 for Scar 2). However, there was no significant difference between the treatment. In the IL triamcinolone group, all patients reported pain and 70.6% observed necrotic skin reaction. There was a significantly higher rate of adverse effects such as erythema (41.2 vs. 17.6%), hypopigmentation (35.3 vs. 23.5%), telangiectasia (41.2 vs. 17.6%) and skin atrophy (23.5 vs. 5.9%) documented in the IL triamcinolone group when compared to clobetasol propionate 0.05% cream under occlusion with silicone dressing. Conclusion Clobetasol propionate 0.05% cream under occlusion with silicone dressing is equally effective and has fewer adverse effects compared to IL triamcinolone. Hence, it may be used as an alternative treatment for keloid particularly in patients with low pain threshold, needle phobia and those who prefers home-based treatment