title: Topical therapies for the treatment of localized plaque psoriasis in primary care: a cost-effectiveness analysis.
abstract: BACKGROUND
  Topical therapies are a mainstay of psoriasis treatment, but they vary substantially in terms of cost.
  
  
  OBJECTIVE
  To determine the cost-effectiveness and optimal treatment sequence for psoriasis of the trunk, limbs and scalp.
  
  
  METHODS
  Probabilities of response from a network meta-analysis were used to determine the short-term efficacy of topical therapies. Longer-term outcomes, including relapse, were informed by published evidence and clinical opinion. Benefits of treatment were measured as quality-adjusted life years (QALYs). Direct costs included topical agents, primary and secondary care visits and second-line therapies for treatment failures.
  
  
  RESULTS
  For the trunk and limbs, initial treatment with a two-compound formulation (TCF) product containing vitamin D and potent corticosteroid provided the most QALYs, followed by separate morning and evening application of vitamin D and potent corticosteroid [two-compound application, TCA (am/pm)], and then twice-daily potent corticosteroids. The use of twice-daily potent corticosteroids was the most cost-effective first-line strategy (incremental cost-effectiveness ratio £ 20,000 per QALY), followed by TCA (am/pm) (£ 22,658 per QALY) and TCF product (£ 179,439 per QALY). For scalp psoriasis, initial treatment with very potent corticosteroids generated the most QALYs, followed by TCF product and then potent corticosteroids. Very potent corticosteroids were the most cost-effective treatment but, if too aggressive, potent corticosteroids were optimal followed by TCF product (£ 219,846 per QALY). The cost-effectiveness of second- and third-line topical agents varied with the assumptions made.
  
  
  CONCLUSIONS
  Potent corticosteroids, used alone or in combination with vitamin D, are the most cost-effective treatment for patients with psoriasis of the trunk and limbs. Potent or very potent corticosteroids are the most cost-effective treatment for patients with scalp psoriasis.
authors: Symmetron Limited, Kinetic Centre, Theobald Street, Borehamwood, Hertfordshire, WD6 4PJ, UK. lsawyer@symmetron.net
authors: L
authors: L
authors: Sawyer
authors: E J
authors: EJ
authors: Samarasekera
authors: D
authors: D
authors: Wonderling
authors: C H
authors: CH
authors: Smith
mesh_terms: D000287:Administration, Topical; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000191:economics*; D003362:Cost-Benefit Analysis; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005121:Extremities; D006801:Humans; D015201:Meta-Analysis as Topic; D008962:Models, Theoretical; D011320:Primary Health Care / Q000191:economics*; D011565:Psoriasis / Q000188:drug therapy / Q000191:economics*; D019057:Quality-Adjusted Life Years; D012535:Scalp / Q000187:drug effects; D060726:Torso; D016896:Treatment Outcome; D014807:Vitamin D / Q000008:administration & dosage / Q000191:economics*
chemical_list: D000305:Adrenal Cortex Hormones; D014807:Vitamin D