A total of 1005 patients with psoriasis or PsA were surveyed in the USA; of these patients, 270 (26.9 %) reported a diagnosis of PsA. The mean age of surveyed patients was 57 years, and 61.3 % were female (Table 1). Approximately 75 % of patients reported at least one comorbid condition, with the most commonly reported conditions being general arthritis, hypertension, depression, diabetes, and heart disease. The mean age at symptom onset was 34 years, and the mean age at the time of patients’ psoriasis diagnosis was 37 years. Patients with PsA reported a mean interval of 12.4 years between onset of skin symptoms and onset of joint symptoms; the mean age at the time of patients’ PsA diagnosis was 44 years.
In the US physician portion of the MAPP survey, 1716 dermatologists and 1235 rheumatologists were screened, and 101 dermatologists and 100 rheumatologists completed the survey (Table 2). Physicians reported an average of 18 years in practice, and 98 % reported that their practice was office based.
More than half of the dermatologists reported that their patients were diagnosed with psoriasis by another physician, while 41.1 % of rheumatologists reported that they had made the diagnosis of PsA themselves. Referrals of patients newly diagnosed with psoriasis or PsA came in large part from primary care physicians (≈55 %). The majority of rheumatologists (73.2 %) reported being solely responsible for prescribing decisions for PsA patients, compared with 28.9 % of dermatologists (Table 2). Approximately one third of the dermatologists and rheumatologists indicated co-management of patients, most commonly with a rheumatologist primarily being responsible for prescribing decisions and a dermatologist also monitoring skin symptoms.
Factors Affecting Disease Severity
Findings from the MAPP survey suggested that psoriasis patients and dermatologists may assess disease severity differently (Fig. 1a). More than one third of patients reported that itching was the most important factor contributing to their disease severity, followed by the location and size of lesions (21.8 %). In contrast, more than three times as many dermatologists (76.2 %) considered the location or size of the skin lesions to be the most important factor contributing to disease severity in their patients with psoriasis, while only one tenth of dermatologists cited itching (11.9 %).
Although PsA patients’ and physicians’ assessments of factors affecting disease severity were more consistent than those of psoriasis patients and physicians, itching continued to be rated as less important by physicians than by PsA patients. Approximately half of the PsA patients reported joint pain and swelling as the most important factors in disease severity (Fig. 1b). This was followed by itching, the location and size of the skin lesions, and flaking. The majority of dermatologists and rheumatologists considered joint pain or swelling to be the most important factor contributing to severity in PsA patients; only 2 % of dermatologists and 2 % of rheumatologists rated itching as the most important factor contributing to disease severity.
These observations are consistent with the global MAPP populations [14, 16] and highlight the differences between patients and physicians in the perception of disease severity and the factors that affect this perception.
Assessment of Joint Pain
Of the psoriasis patients who did not have a diagnosis of PsA, 51.8 % reported joint pain; of these, 48.1 % reported having more than four affected joints. In contrast, dermatologists reported a substantially lower percentage (18.6 %) of their psoriasis patients complaining of joint symptoms. This discrepancy may be due to variations in assessing joint pain (which is also associated with many inflammatory conditions beyond PsA) among patients. However, while most dermatologists reported discussing the possibility of developing joint disease with all (57.4 %) or some (33.7 %) of their psoriasis patients, 87.1 % of dermatologists and 85.0 % of rheumatologists acknowledged that PsA is likely underdiagnosed because of failure to connect skin and joint symptoms. In addition, 37.6 % of dermatologists most often cited differentiating PsA from other arthritic diseases as the greatest challenge in managing PsA patients, while 25.0 % of rheumatologists cited delayed referral as one of their greatest challenges.
Physician Attitudes: Challenges in Patient Management
Both dermatologists and rheumatologists reported that the management of patients with psoriasis and PsA can be challenging. According to 68.3 % of the dermatologists, their psoriasis patients require more time and support than patients with other medical concerns, with 24.8 % reporting management of psoriasis patients as complicated and 34.7 % reporting it as time consuming. In addition, 32.7 % of dermatologists reported that managing patients with PsA was complicated, while 26.7 % of dermatologists said that managing these patients was time consuming. However, only 6.9 % of dermatologists thought they would need to refer to or involve other specialists in the care of their PsA patients (and only 1 % thought they would need to involve other specialists in the care of their psoriasis patients). Of the rheumatologists surveyed, 23 % reported that their PsA patients require more time and support than their other patients.
In addition to the challenges of differentiating PsA from other arthritic conditions, dermatologists also cited challenges with the therapies for psoriasis and PsA, such as affordability (28.7–57.4 %), lack of long-term safety (8.9–16.8 %), and lack of effectiveness (12.9–14.9 %). Similarly, in addition to delayed referral, rheumatologists most often cited affordability (39 %), lack of effectiveness (19 %), and lack of long-term safety (9 %) of current medications as the greatest challenges in treating PsA patients.
Medical Care and Treatment Patterns
Patient Use of Medical Care
Among the psoriasis patients, 42.6 % reported that they had not seen an HCP in the previous 12 months. Of the 57.4 % of psoriasis patients who had seen an HCP in the previous 12 months, 56.9 % had seen a dermatologist and 30.2 % had seen a primary care physician (Table 3). The most common reasons that psoriasis patients cited for not seeing an HCP were that the symptoms were not bad enough, there were no symptoms, they did not think an HCP could help, the current treatment was working, or they were unable to get an appointment (Table 3).
In contrast, the majority of PsA patients (85.6 %) had seen an HCP in the previous 12 months; these patients reported most often seeing a rheumatologist for their PsA, followed by a primary care physician and a dermatologist (Table 3). The reasons cited by PsA patients for not seeing an HCP in the previous year generally were similar to those cited by psoriasis patients, including that their symptoms were not bad enough, they did not think an HCP could help, there were no symptoms, the current treatment was working, and the cost or lack of insurance (Table 3).
Overall, patients reported lower rates of current treatment than dermatologists and rheumatologists, with substantial differences noted in use of biologic therapy by psoriasis and PsA patients and use of conventional oral therapy by PsA patients (Tables 4, 5). Fewer than 10 % of psoriasis patients reported use of conventional oral therapy or biologic therapy, compared with approximately 25 % of PsA patients reporting use of each treatment. While 50 % of PsA patients reported use of systemic therapy, half reported no treatment or reported use of topical medications only, leaving their joint disease untreated.
According to the physicians surveyed, use of conventional oral and biologic therapies was much higher than that reported by patients. Dermatologists reported use of conventional oral therapy in 12.7 % of their psoriasis patients and 22.9 % of their PsA patients, while rheumatologists reported use in 57.1 % of PsA patients. Dermatologists reported use of biologic therapy in 35.8 % of psoriasis patients and 46.9 % of PsA patients, while rheumatologists reported use of biologic therapy in 52.7 % of PsA patients. Some of these discrepancies in reported treatment rates probably arose because patients were not required to be seeing an HCP or receiving treatment to participate in the MAPP survey. However, even the proportion of physician-reported treatment indicates a level of undertreatment.
Treatment Challenges and Burdens
Conventional Oral Therapy
Of the 250 respondents who had ever used conventional oral therapies, about half found them burdensome. The reasons for the treatment burden most often cited by patients were adverse effects and the need for laboratory monitoring (Fig. 2a). Patients most commonly discontinued conventional oral therapy because of safety and tolerability issues, or lack or loss of effectiveness (Fig. 3a). Similarly, the main reasons for dermatologists and rheumatologists not initiating or maintaining conventional oral therapy in psoriasis and PsA patients were related to long-term safety and tolerability concerns (Fig. 3b, c). In addition, one quarter of rheumatologists also cited lack of effectiveness as the main reason for not initiating conventional oral therapy for their PsA patients. Of the physicians who did not prescribe conventional oral therapy, because of patient refusal or concerns, the most common patient concerns were related to long-term safety, tolerability, and lifestyle modifications.
Among 90 patients who were using injectable biologics at the time of the survey, anxiety and fear related to injections and side effects were the most common reasons that 27 % cited for finding them burdensome (Fig. 2b). As with conventional oral therapy, patients most commonly discontinued biologic therapy because of safety and tolerability concerns, and lack or loss of effectiveness; however, 13.7 % of patients also reported cost as a reason for discontinuing biologic therapy (Fig. 4a).
Broad use of biologic agents was reported by three quarters of rheumatologists versus one third of dermatologists, yet 82.2 % of dermatologists (versus 99.0 % of rheumatologists) said they would initiate and manage biologic therapy themselves if their patient were a candidate. The main reasons that dermatologists and rheumatologists cited for not initiating or continuing biologic therapy were related to long-term safety and tolerability issues, as well as cost (Fig. 4b, c).
Satisfaction with Current Treatment Options
The majority of psoriasis and PsA patients were somewhat satisfied or very satisfied with the effectiveness of conventional oral therapy (56.9 and 69.5 %, respectively) or biologic therapy (77.7 and 83.5 %, respectively), with more PsA patients than psoriasis patients reporting satisfaction. However, 33.9 % of psoriasis patients and 39.7 % of PsA patients reported being dissatisfied with the long-term safety of conventional oral therapy. Dissatisfaction with the long-term safety of biologic therapy was reported by 31.8 % of psoriasis patients and 25.2 % of PsA patients. Overall, 31.3 % of psoriasis patients and 40.7 % of PsA patients reported that their primary goals of therapy, including keeping symptoms at bay, reducing itching, and decreasing flaking, were not met with their current treatment.
In general, more physicians than patients reported satisfaction with treatment effectiveness. Among dermatologists, 76.3 % reported satisfaction with conventional oral therapy effectiveness and 99.0 % reported satisfaction with biologic therapy effectiveness, while 69.0 and 97.0 % of rheumatologists, respectively, reported satisfaction. However, 53.2 % of dermatologists and 17.0 % of rheumatologists were dissatisfied with the long-term safety of conventional oral therapies; 17.8 % of dermatologists and 15.0 % of rheumatologists reported dissatisfaction with the long-term safety of biologic agents. Nearly 80 % of dermatologists and more than 50 % of rheumatologists reported that they were somewhat or very concerned about the overall long-term use of conventional oral or biologic therapy.
Overall, most survey respondents (87.8 % of patients, 98.0 % of dermatologists, and 98.0 % of rheumatologists) felt there was a strong or moderate need for better therapies. Among patients, 51.5 % indicated that current therapies can be worse than the condition itself, compared with 30.7 % of dermatologists and 12.0 % of rheumatologists. In addition, 48.5 % of dermatologists and 31.0 % of rheumatologists reported that an important issue is patients leaving their practice because of frustration or dissatisfaction with currently available therapies.