Florek2018 Article TreatmentPreferencesAndTreatme

Archives of Dermatological Research (2018) 310:271–319
https://doi.org/10.1007/s00403-018-1808-x
ORIGINAL PAPER
Treatment preferences and treatment satisfaction among psoriasis

patients: a systematic review
Aleksandra G. Florek1 · Catherine J. Wang2 · April W. Armstrong2,3
Received: 17 September 2017 / Revised: 21 December 2017 / Accepted: 12 January 2018 / Published online: 13 February 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
Abstract
A critical gap exists in determining treatment preferences and treatment satisfaction from patient perspectives, which is para-
mount to achieving therapeutic success. The objective of this systematic review is to determine factors influencing treatment
preferences and treatment satisfaction among psoriasis patients. PubMed, EMBASE, and Web of Science databases were
searched between November 1, 2010, and December 1, 2017. Observational and interventional research studies published in
the English language that discussed patient preferences and patient satisfaction in the treatment of psoriasis were reviewed
and synthesized. We utilized data on treatment preferences and treatment satisfaction from 35,388 psoriasis patients based
on 60 articles from the years 2010 to 2017. Treatment preferences were heterogeneous and changed over time among pso-
riasis patients. Across all treatment modalities, the most important treatment attributes were treatment location, probability
of improvement, and delivery method. For biologics specifically, the most important attributes were risk of adverse events
and probability of treatment benefit. Factors that influenced patients’ preferences for certain treatments included age, sex,
comorbidities, disease duration, and prior treatments. Notably, some psoriasis patients placed higher importance on a treat-
ment’s process attributes (e.g., access and delivery) over its outcome attributes (e.g., efficacy). Overall, patient satisfaction
with existing therapies remains modest; however, those treated with biologic agents exhibited highest treatment satisfaction
over oral therapy, phototherapy, and topical therapy.
Keywords Psoriasis · Patient preference · Patient participation · Treatment satisfaction
Introduction satisfaction globally. Studies have shown that discordance

sometimes exists between physician-reported versus patient-
Psoriasis is a chronic, inflammatory systemic disease that reported outcomes; furthermore, physician perception of
affects 3.2% of the U.S. adult population [45]. Different treat- patients’ treatment preferences and satisfaction can often be
ment modalities exist for psoriasis patients, including topical inaccurate [58]. Determining patient treatment preferences
medications, phototherapy, oral systemic medications, and and satisfaction is paramount to achieving therapeutic suc-
biologics [21, 37–40]. While a myriad of data exists for effi- cess and improving overall quality of life. This systematic
cacy and safety of novel agents in psoriasis, a gap exists in review addresses this gap in the literature and provides an
the literature regarding patients’ treatment preferences and engaging synthesis on treatment preferences and satisfaction
from psoriasis patients’ perspective.
Aleksandra G. Florek and Catherine J. Wang contributed equally

Conceptual framework: treatment preferences
to the manuscript as co-first authors.
* April W. Armstrong Patient preferences are values that patients assign to various
aprilarmstrong@post.harvard.edu aspects of health or health care. Patient treatment preferences
1 refer to the value that patients assign to distinct attributes of
University of Colorado Denver School of Medicine, Denver,
CO, USA psoriasis treatments. Treatment attributes can be divided into
2 treatment process attributes and outcome attributes (Table 1)
Keck School of Medicine, University of Southern California,
Los Angeles, CA, USA [26, 31, 32, 54–56, 59, 67, 69, 70]. Treatment process attrib-
3 utes include treatment location, frequency, duration, route
University of Southern California, Los Angeles, CA, USA
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272 Archives of Dermatological Research (2018) 310:271–319
Table 1 Conceptual framework of treatment attributes

Treatment outcome attribute Example Selected literature findings
Probability of treatment benefit Chance that patient will experience improvement with Younger patients were more interested in probability of
treatment, e.g., 90, 75, 50% treatment benefit than older patients [31, 32, 56, 70]
Magnitude of treatment benefit Difference between a patient’s baseline severity and Patients receiving older systemic treatment for psoriasis
clearance, e.g., PASI 75 and PASI 50 attached greater importance towards magnitude of
treatment benefit [57]
Time until treatment benefit Length of time until patient experiences improve- Patients preferred treatments with faster onset of
ment, e.g., 1, 2 days, 1 week improvement (time until treatment benefit) [67]
Duration of treatment benefit Length of time patient experiences improvement after Patients with longer disease duration attached greater
treatment completion, e.g., 1, 2, and 6 months importance to duration of treatment benefit [57]
Probability of side effects Chance that patients will experience side effects with Patients with cardiovascular disease were highly con-
treatment, e.g., 10, 20, and 50% cerned about the probability of side effects [54, 59]
Reversibility of side effects Probability that treatment side effects will completely Patient rated reversibility of side effects as one of the
disappear, e.g., 100, 75, and 50% least important attributes [56]
Treatment process attribute Example Selected literature findings
Location Location where treatment will take place, e.g., Location was the most important treatment attribute
patient’s home, hospital, physician’s office, and [56]
outpatient clinic
Frequency How often treatment occurs, e.g., twice daily, once Women were more interested in treatment frequency
daily, biweekly, and monthly than men [32]
Duration How long it takes to complete the treatment, e.g., Patients on phototherapy and topical therapy were more
5 min or half an hour interested in treatment duration [31]
Route of administration How treatment will be administered, e.g., IV, subcuta- Patients preferred quarterly subcutaneous or monthly
neous injection, and oral IV routes of administration over daily oral administra-
tion [67]
Formulation Form treatment is presented as, e.g., gel, ointment, Patients preferred gel formulation over ointment for
foam, and cream treatment of hairy scalp [27]
Cost How much patient pays for treatment, e.g., nothing, Cost was more important to females and to older
$100/month, and $200/month patients [67]
of administration, formulation, and cost. Treatment outcome plans through shared decision making, which contributes
attributes include treatment benefit (probability of treat- to greater treatment adherence, satisfaction, and improved
ment benefit, magnitude of treatment benefit, duration of health outcomes.
treatment benefit, and time until treatment benefit) and side
effects (probability, severity, and reversibility). Factors that Conceptual framework: treatment satisfaction
may impact patient preferences for these treatment attrib-
utes include age, gender, income, employment, marital status, Treatment satisfaction is the degree to which the patients
health-related quality of life, type of baseline inflammatory perceive the treatment fulfills their health needs [60]. Treat-
disease, psoriasis duration, concomitant diseases, concurrent ment satisfaction often reflects patients’ experience with the
treatments, and healthcare utilization patterns [1, 5, 6, 13, treatment process and their clinical outcomes. Treatment
25–27, 31, 46, 54–57, 59, 67, 70]. satisfaction can be affected by a number of different fac-
Multiple formats exist for eliciting treatment preferences tors, such as demographic and socioeconomic characteris-
from patients. These include semi-structured group discus- tics, psoriasis severity, comorbidities, treatment process and
sions, semi-structured telephone interviews [10, 12, 14, outcomes attributes, and patient perception of the provider
63], or study-specific surveys eliciting patient preferences [14, 29, 43].
[1, 4–6, 16, 20, 25–27, 30, 36, 47, 50, 52, 75, 76]. Methods An important relationship exists between patient prefer-
for evaluating patient preferences include discrete choice ence and patient satisfaction. For example, when patient
experiment, time trade-off, and willingness to pay [23, 31, preferences are elicited and incorporated into treatment deci-
32, 46, 54–57, 59, 67–70, 75]. Some studies inquired patient sion making, the physician–patient decision on treatment
treatment preferences regarding treatment process, outcome selection is likely more aligned with patient values. In these
attributes, or both. Identifying patient treatment preferences cases, patients are more likely to report greater satisfaction
is the foundation for devising individualized treatment with the treatment, because they had played an active role
13
Archives of Dermatological Research (2018) 310:271–319 273
in the decision-making process [33, 68, 69]. Furthermore, 1, 2017. Figure 1 shows a flow diagram displaying the
while patients’ initial treatment preferences can lead to search process. After removal of duplicates, 400 citations
selection of a particular treatment, their subsequent satis- were manually selected for additional assessment. We then
faction invariably affects their future treatment preferences. excluded 333 abstracts for the following reasons: 131 were
The objective of this systematic review is to identify fac- not about patient preferences or patient satisfaction; 86 were
tors influencing treatment preferences and treatment satisfac- conference abstracts or papers; 56 were review articles; 35
tion among psoriasis patients. This understanding is funda- were editorials, commentaries, notes, or letters; 12 were
mental to improving overall patient outcomes. published outside of the date range that we included; eight
ascertained physician preferences and/or satisfaction; four
referred to assessing adherence only; and one was a case
Methods report. After reading the abstracts, we performed a full-text
review of 67 studies. Upon evaluation of the full text of
Search strategies 67 records by study investigators, we further eliminated 20
records: 11 contained a very limited discussion that inhibited
We performed a systematic search using PubMed, EMBASE, proper evaluation; five were review articles; three were not
and Web of Science search engines for articles that elicited about patient preferences or patient satisfaction in psoriasis
patient preferences and treatment satisfaction in psoriasis. treatment; and one article did not have full text. Thirteen
We performed the search with the following terms: (“patient additional articles were identified after manually search-
preference” OR “patient preferences” OR “patient involve- ing the reference lists of relevant articles. Three authors
ment” OR “patient decision” OR “patient decisions” OR extracted the data from the final 60 articles. Any disagree-
“patient choice” OR “patient choices” OR “shared decision ments were resolved by consensus.
making” OR “patient participation” OR “patient centered
care” OR “decision support techniques” OR “treatment
satisfaction”) AND “psoriasis”. We also included avail- Results
able MeSH and Emtree terms from PubMed and EMBASE,
respectively. Our search was limited to the English language, After applying inclusion and exclusion criteria, we included
and human-subject studies published between November 1, 60 studies for synthesis for this systematic review on treat-
2010 and December 1, 2017. We also manually searched the ment preferences and treatment satisfaction from 35,388
reference lists of relevant articles for any additional studies psoriasis patients. Specifically, we included 34 studies on
not identified in the initial searches. Included articles were patient treatment preferences from 17,916 psoriasis patients
screened, selected, and critically appraised using pre-defined and 26 studies on patient treatment satisfaction from 17,472
inclusion and exclusion criteria. The initial search yielded psoriasis patients. This systematic review included 35 cross-
603 results: 127 from PubMed, 336 from EMBASE, and 140 sectional studies, five randomized controlled trials, 10 pro-
from Web of Science. spective cohort studies, and one case series. Study char-
acteristics and findings for the articles that elicited patient
Inclusion and exclusion criteria preferences are found in Table 2, and study information and
outcomes for the articles that solicited patient treatment sat-
To be included, original studies needed to fulfill the fol- isfaction are found in Table 3.
lowing inclusion criteria: peer-reviewed original studies that
used assessment tools to evaluate patient treatment prefer- Patient preferences for treatment attributes
ences and treatment satisfaction in psoriasis. We excluded
the following types of publications: case reports, commen- Treatment attributes include process and outcome attrib-
tary, editorial, note, letter, conference abstract, reviews, utes. From the 34 studies that examined 17,916 psoriasis
articles lacking assessment tools to evaluate treatment patients (Table 2), a number of factors influenced patient
preferences or satisfaction, or limited discussion of patient preferences [1, 12, 20, 25, 26, 47, 50, 55–57, 59, 63, 67,
treatment preferences and satisfaction that inhibits adequate 70, 76]. Overall, when synthesizing literature across
evaluation. all treatment categories, we found that the factors most
important for patient preference were treatment location,
Study selection probability of benefit, and route of administration [56]. For
example, younger patients were more interested in proba-
Based on the aforementioned inclusion and exclusion cri- bility of treatment benefit than older patients were [31, 32,
teria, we identified 603 initial citations from the electronic 55, 56, 70]. Treatment preferences changed over time and
search published between November 1, 2010 and December with treatment experience; that is, psoriasis patients with
13

603 records identified through database searching

127 records identified from PubMed
336 records identified from EMBASE
140 records identified from Web of Science
400 unique records after 203 duplicate records

duplicates removed removed
400 records screened 333 records eliminated after reviewing abstracts:

131 not about patient preferences or satisfaction
in psoriasis treatment
86 conference abstracts or conference papers
56 review articles
35 editorial, commentary, note, letters
12 published outside of the inclusionary date
67 records range
assessed for 8 ascertained provider preferences or
inclusion satisfaction
4 referred to assessing adherence only
1 case report
13 additional 47 relevant 20 full text articles excluded with reasons:

articles articles 11 contained a very limited discussion
manually located on preferences and satisfaction that
identified inhibited adequate evaluation
5 review articles
3 not about patient preferences or
patient satisfaction in psoriasis
treatment
1 full text not available
60 studies included in
qualitative analysis
Fig. 1 Flowchart for patient preferences and satisfaction in psoriasis treatment: systematic review of the literature
longer disease duration attached greater importance to the as DLQI score increased, patient’s interest in probability
duration of treatment benefit [57]. Impact on quality of of improvement decreased [5, 32]. Finally, the presence of
life also influenced patients’ treatment preferences. Stud- comorbidities affected patient preferences towards various
ies showed that patients with a Dermatology Life Quality treatments [54, 59]. For instance, patients with psoriatic
Index (DLQI) score of greater than 10 were more tolerant arthritis cared most about the probability of benefit [59],
of adverse effects [13]. Another two studies showed that
13
Table 2 Patient preferences in psoriasis treatment
Study Study country; Study design Number of pso- Demographics Psoriasis char- Preference- Therapies Outcome Outcomes Quality
setting; time riasis patients of psoriasis acteristics elicitation measure(s) ratinga
period patients method
Alcusky et al. • USA Cross sectional 196 • Mean age • 45% reported Conjoint • Systemic Two versions of the • Patients with 4
[1], 2017 • Outpatient NR moderate pso- analysis/dis- • Biologic DCE survey with moderate psoria-
• NR • 40% male riasis when crete choice 8 treatment choice sis rated dosing as
disease was at experiment questions with the the most impor-
its worst (DCE) following attrib- tant treatment
• 55% reported utes: probability attribute, followed
severe pso- of improvement by probability of
riasis when as measured by improvement
disease was at PASI and BSA • Patients with
its worst after 16 weeks of severe psoriasis
treatment, prob- preferred treat-
ability that DLQI ments with high
will improve probability of
after 16 weeks improvement,

of treatment, followed by
probability of loss quality-of-life
of response after improvement
1 year due to non- • Patients with
efficacy reasons, severe psoriasis
probability of considered safety
AE, probability relatively less
of severe AE, and important
dosing
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275

Table 2 (continued)
276
13
Hong et al. [25], • Canada, Ger- Phase IIIb, 212 • Mean age • 84% reported 6 question- Topical TPUQ included • Patient prefer- 1
2017 many open-label, NR duration naires: 2 questions with ence for Cal/BD
• Outpatient randomized, • 63% male of psoria- in-licensed the following foam and gel were
• NR two-arm sis < 5 years (DLQI and domains 50:50
crossover • 58% moderate Vehicle • Application • Younger patients
study psoriasis Preference • Formulation preferred foam,
Measure • Container older patients
[VPM]); 4 • Satisfaction preferred gel
developed by • Cal/BD foam
LEO Pharma had higher mean
in collabora- scores for certain
tion with formulation items
an external • Mean TPUQ
research scores higher for
agency (Top- foam > gel > latest
ical Product topical treatment
Usability (LTT)
Question-
naire
[TPUQ],
Comparison
to Latest
Topical
Treatment
[CLTT],
Subject’s
Preference
Assess-
ment [SPA],
Subject’s
Assessment
of Behavior
and Attitudes
[SABA])
Schaarschmidt • Germany Cross sectional 222 • Mean age • Mean dura- Conjoint • Systemic RIS for: • Patients preferred 4
et al. [55], • Outpatient 50.3 years tion of psoria- analysis/dis- • Biologic • Treatment out- treatments with
2017 • 9/2015 • 64% male sis 22.2 years crete choice come attributes probability of
–8/2016 • Mean DLQI experiment (probability of PASI 90 response,
7.5 (DCE) PASI 75 and 90 followed by mild
response, time AE and severe AE
until response, • Older patients
probability of considered prob-
mild and severe ability of PASI
AE) 90 less important
• Treatment and mild AE and
process attributes treatment location
(treatment loca- more important
tion, frequency, • Patients with

delivery method, increased disease
frequency of labo- severity consid-
ratory tests and ered severe AE
cost to the health- less important
care system)
13
277

278
13
Eliasson et al. • UK Cross sectional 292 • Mean age • Mean age at Conjoint • Biologic 32 treatment profile • Preferred once- 4
[13], 2017 • Outpatient 48.5 years diagnosis 35.8 analysis • Non- pairs were used weekly tablets
• NR • 49.3% male • Mean dura- biologic to create two ver- over twice-daily
tion of psoria- sions of the DCE tablets and injec-
sis 12.6 years survey with 16 tions
• Mean DLQI sets each with the • Patients DLQI
10.5 following attrib- score > 10 more
utes: reduction in tolerant of adverse
body surface area events
affected, treat- • Patients DLQI
ment administra- score ≤ 10 pre-
tion, short-term ferred to avoid
diarrhea or nausea injectable treat-
risk, 10-year risk ments over once-
of developing weekly tablets
melanoma or
nonmelanoma
skin cancer, tuber-
culosis, or serious
infections
Kromer et al. • Germany Cross sectional 200 • Mean age • Mean PASI Conjoint Biologic RIS for: • Most important 4
[31], 2017 • Outpatient 50.8 years 3.4 analysis • Treatment process outcome attributes
• 3/2013– • 57.5% male • Mean DLQI attributes (loca- were severe AE
9/2013 6.2 tion, frequency, and 90% improve-
• Mean disease duration, delivery ment
duration method) • Patients treated
19.9 years • Treatment out- with topical
• 22.5% PsA come attributes therapy or pho-
(probability of totherapy were
50% improve- more interested in
ment, probability treatment duration
of 90% improve- • Patients with tra-
ment, time until ditional systemic
response, sustain- medication were

ability of success, more worried
probability of about sustain-
mild AE, probability of success
ability of severe and treatment
AE, probability of frequency
ACR 20 response) • Biologic-expe-
• Attribute levels rienced patients
were more inter-
ested in sustain-
ability
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279

280
13
Zhang et al. • United States Cross sectional 426 • Mean age • 36% biologic- Study-specific • Biologic • Likelihood of • Biologic-naïve 4
[75], 2017 • Outpatient biologic- experienced survey asking • Non- choosing 1-, 2-, or and biologic-
• 1/2012– naïve patients 2 questions biologic 12-week dosing experienced
7/2013 patients reported about dosing interval options patients preferred
51 years severe pso- frequency • Chosen intervals, the least frequent
• Mean age riasis preferences by experience dosing option of
biologic- • 23% biologic- with specific once every 12
experienced naïve patients biologics weeks
patients reported • Patients with
49 years severe pso- experience with
riasis ustekinumab
preferred a dosing
interval of 2–3
months
• Patients with
experience with
adalimumab
or etanercept
preferred a dosing
interval of 1–2
weeks
Radtke et al. • Germany Cross sectional 1265 • Median age • 17.4% had PBI- study- • Topical 25 potentially • Most important 4
[46], 2016 • Outpatient 52 years PsA (14.2% specific • Systemic relevant treatment treatment goals
• 2005, 2007, • 43.4% previously survey asking • Bio- needs regarding were skin heal-
2014 female diagnosed, patients logic + sys- the following ing and quick
• 62.0% work- 3.2% newly before temic dimensions: improvement of
ing suspected) therapy about • Biologic • Reduction of the skin
• 84.5% suf- the benefits social impair- • Most important
fered from of treatment ments physical symptom
plaque-type personally • Psychological goal was reduc-
psoriasis important impairments tion in itching,
to him/her; • Impairments due then burning sen-
during or to therapy sations and pain
after therapy, • Physical impair- • Ability to lead a
patients ments normal everyday
stated • Having confi- life was rated
to what dence in healing more important
extent the than productivity
previously- in everyday life
defined aims and normal work
of treatment life
were met
Blome et al. [6], • Germany Prospective • 3066 patients • Mean age • On aver- PBI-S from • Systemic 25 different treat- • Skin healing and 2
2016 • Outpatient cohort at baseline 47.2 years age, first German pso- • Biologic ment goals rated quick improve-
• NR • 1444 at • 59.6% male diagnosis of riasis registry for importance ment of the skin
follow-up psoriasis was “PsoBest”— regarding the were the most
(average 18.3 years survey asking following dimen- important goals
378 ± 41 days prior patients sions: • Most important
after baseline • Mean PASI before • Reduction of physical symptom
visit) 14.5 ± 9.6 therapy about social impair- goal was reduc-
the benefits ments tion in itching
of treatment • Psychological • Ability to lead a
personally impairments normal everyday
important to • Impairments due life was rated
him/her to therapy important
during or after • Physical impair- • At follow-up,

therapy, ments goals that became
patients • Having confi- more important
stated dence in healing were more contact
to what with people, fewer
extent the side effects, and
previously- better sleep
defined aims
of treatment
were met
13
281

282
13
Schaarschmidt • Germany Cross sectional 200 • Mean age • Mean PASI Conjoint Biologic RIS for • Patients assigned 4
et al. [54], • Outpatient 50.8 years 3.4 analysis • Treatment process greatest value to
2015 • NR • 57.5% male • Mean DLQ1 attributes (loca- risk of severe AE,
6.2 tion, frequency, followed by prob-
• 22.5% PsA delivery method, ability of 90%
• 31.5% arterial duration) improvement and
hypertension • Treatment out- risk of mild AE
• 22.5% PsA come attributes • Patients with PsA
• 15% car- (probability of placed greater
diovascular 50% improve- importance on
disease ment, probability ACR 20 response,
• 14.5% dia- of 90% improve- sustainability
betes ment, time until of success and
• 26% chronic response, sustain- severe AE
bronchitis or ability of success, • Patients with
asthma probability of cardiovascular
mild AE, prob- disease were
ability of severe worried about
AE, probability of mild AE, severe
ACR 20 response) AE and ACR 20
response
• Patients with dia-
betes were more
interested in treat-
ment duration
Blome et al. [5], • Germany, Multi-center 203 • Mean age • Mean psoria- NAPPA-PBI— • Topical 24 potentially • Most important 2
2016 Denmark, prospective 49.3 years sis diagnosis survey asking • Systemic relevant treatment goals were to
Italy, Spain, cohort • 68.5% male age 15.7 years patients • Biologic goals regarding have confidence
USA, Japan • 61.6% before the following in therapy, gain
• Outpatient patients’ therapy about dimensions control of disease,
• NR finger and toe the benefits • Reduction of have normal look-
nails affected of treatment social impair- ing nails, and find
• 26.6% only personally ments a clear diagnosis
fingers important • Psychological and therapy
affected to him/her; impairments • Patients < 50 years
• 5.4% only during or • Impairments due found it important
toes affected after therapy, to therapy to have firm nails
• Mean PASI patients • Physical impair- • Patients with high
6.8 stated ments QoL impairment

to what • Having confi- stated high overall
extent the dence in healing goal importance
previously-
defined aims
of treatment
were met
13
283

284
13
Iversen et al. • UK Non-randomized 112 Median age 49.1% patients 16 question Topical • Women ranked
• Easy accessibility 2
[27], 2016 • Outpatient controlled trial 40–49 years suffered study-spe- of product out of products that were
• 11/2014– psoriasis for cific survey container easy to spread
12/2014 and ≥ 15 years assessing • Quantity control onto the skin of
1/2015 13 topical Precise application higher importance
treatment • Non-greasy skin • Ointment was
attributes • Non-greasy hair preferred over the
• Odorless two gel presenta-
• Visibility on skin tions for treatment
• Use of fingers of neck and hairy
with application back/buttocks
• Mess with use • Patients preferred
• Time to apply gel formulation
• Quick absorption over ointment for
• Same product for treatment of hairy
all areas affected scalp
• Easy to spread • Patients preferred
gel Applicator
than gel in tube or
ointment in tube
for more plaque
locations
Reich et al. [50], • Denmark, Randomized, 1795 • Mean age • Mean dura- PPQ (a study- Topical Patient preference Patients rated the 1
2015 France, multi-center, 50.9 years tion of psoria- specific with the current current topical
Germany, phase IV trial • 57.6% males sis 17.7 years survey on fixed combination fixed combination
Italy, The • 8.5% had PsA patient pref- treatment, com- gel to be more
Netherlands, • Mean PASI erence for pared with any effective, easier
Spain, Swe- 4.50 the current previouspsoriasis to use, have less
den, United • Mean PGA treatment therapy received side effects, and
Kingdom at baseline 3 compared be more tolerable
• Outpatient (on a 7-point with previous than previous
• NR scale) treatment, treatments they
containing received (whether
10 questions topical or sys-
scaled on a temic)
4-point Lik-
ert scale)
Kromer et al. • Germany Cross sectional 200 • Mean age • Mean PASI Conjoint Biologic RIS for • Most important 4
[32], 2015 • Outpatient 50.8 years 3.4 analysis • Treatment process attributes: prob-
• NR • 57.5% male • Mean DLQI attributes (loca- ability of severe
6.2 tion, frequency, AE, probability of
delivery method, 90% improvement
duration) and probability of
• Treatment out- mild AE
come attributes • Women were
(probability of more concerned
50% improve- with treatment
ment, probability frequency
of 90% improve- • Older patients
ment, time until were less con-
response, sustain- cerned with prob-

ability of success, ability of 50% and
probability of 90% improvement
mild AE, prob- • As RIS for prob-
ability of severe ability of 50%
AE, probability of improvement
ACR 20 response) increased, DLQI
decreased
13
285

286
13
Eastman et al. • United States Cross sectional 17 (in addition, • Mean age Mean disease Semi-struc- Topical • Preferences for • Creams, oint- 4
[12], 2014 • Outpatient 19 patients 52.2 years duration tured group product vehicles ments, and foams
• 3/2012– with acne and • 47.1% males 17.8 years discussion in • Preferences for were the most
4/2012 18 patients focus groups product attrib- preferred vehicles
with AD were utes (43 various among psoriasis
included) attributes of topi- patients
cal treatments— • Moisturizing was
examples include: the most consist-
moisturizing, ently valued
available in vari- attribute in all
ous formulations, focus groups
not greasy or oily, • Others also
long lasting, easy highly valued
to apply, odor were: absorbs/
free, not sticky, disappears/dries
not greasy, can quickly, avail-
use during all the able in various
seasons or dif- formulations, does
ferent activities, not bleach or stain
soothing, steroid- skin/hair/clothing,
free, exfoliating, is not greasy or
etc.) oily, is not sticky
or tacky, is long
lasting/long act-
ing, is fragrance
or odor free, is
easy to apply/sim-
ple to use, and can
use all the time
Sandoval et al. • United States Open-label, 20 • Median age Median IGA Study-specific Topical • Mean total prefer- The topical suspen- 1
[52], 2014 • Outpatient investigator- 48.0 years score 3 (on a survey ence score for sion formulation
• 1/2013– blinded, • 65% males 5-point scale) containing each study drug of calcipotriene
3/2013 crossover, questions • Median value for 0.005% beta-
randomized regarding individual survey methasonedipro-
controlled patient’s questions and pionate 0.064%
study experience treatment adher- was preferred by
with the ence psoriasis patients
study drug, over the ointment
overall (p = 0.32)
appeal, using
a 7-point
grading scale
Augustin et al. • United States, Prospective 203 in the vali- • Mean age • Mean NAPPA-PBI— • Topical • Before therapy, • Patients assigned 2
[4], 2014 Germany, cohort (valida- dation study 49.3 years duration of a survey elic- • UV patients rated the highest benefit to
Denmark, tion study) • 68.5% males psoriasis iting patient therapy importance of 24 biologics (2.30),
Japan, Italy, 15.7 years preferences • Systemic different treatment then to topical
Spain • 30.0% had and the • Biologic goals using a therapies (2.05),
• Outpatient PsA attainment 5-option sale from then to oral sys-
• NR • Mean dura- of patient- “not important temic treatment
tion of nail relevant at all” to “very (1.87), and lastly
psoriasis was treatment important” to UV therapy
11.4 years goals • During or after (1.18)
therapy, patients • NAPPA-PBI
rated the extent to scores correlated
which the treat- moderately with
ment helped each clinical outcomes

of the 24 previ- and other quality-
ously identified of-life question-
goals naires (NAPSI
and EQ-5D)
• NAPPA is a valid,
reliable, practical
tool to assess
patient-relevant
benefit in treat-
ment
13
287

288
13
Zschocke et al. • Germany, Cross sectional 59 NR NR TTAQ and Topical • Patient preference • Based on the 4
[76], 2014 Spain, Den- PPQ—study- • Patient satisfac- initial feasibility
mark, Sweden, specific tion with treat- test, TTAQ and
The Nether- surveys ment PPQ are psycho-
lands assessing • Patient benefit metrically sound
• Outpatient treatment from treatment and reliable tools
• 1/2011– adherence • Information, for assessing fac-
4/2011 and prefer- communication, tors that influence
ences of and relationship topical treatment
patients towards the doctor adherence
• TTAQ and PPQ
will enable physi-
cians to assess
adherence risk
factors and patient
preferences prior
to beginning treat-
ment
Torbica et al. • Italy Cross sectional 243 • Mean age • Mean age Conjoint Topical Treatment attrib- • Patients pre- 4
[67], 2014 • Outpatient 48.8 years at psoriasis analysis (also Systemic utes (mode and ferred quarterly
• 2011 • 62.1% males diagnosis was known as dis- Biologic frequency of subcutaneous or
29.5 years crete choice administration, monthly IV route
• Mean PASI experiment) time to improve- of administra-
16.5 ment, time free tion (compared
• Mean BSA of symptoms, to daily oral) and
covered by unintended life treatments with
lesions 21.8% expectancy reduc- faster onset of vis-
• 22% had tion resulting ible improvement,
concomitant from treatment, treatments with
hypertension and monthly treat- longer symptom-
• 6% had con- ment cost) free periods,
comitant PsA less expensive

treatments, and
treatments with a
lesser reduction in
life expectancy
• Preferences vary
according to sex,
age, and disease-
related quality
of life
• Cost was more
important to
females and to
older patients
13
289

290
13
Sylwestrzak • United States Cross sectional 62 (in addi- • Mean age N/A Study-specific Biologic • Patient prefer- • Regardless of 4
et al. [63], • Outpatient tion, 73 had 49.8 years in telephone ence for route of condition, patients
2014 • 11/2012– PsA, 155 had the IV anti- or Internet- administration of receiving SC
12/2012 Crohn’s dis- TNF user based anti-TNFs agents had a
ease, and 293 group survey asking • Patient satisfac- higher preference
had RA) • 30.7% males patients tion measured for the medica-
in the IV about their using TSQM tion they were
anti-TNF anti-TNF use, version II receiving com-
user group preferences pared with those
• Mean age for mode of receiving infusion
49.4 years in administra- therapies
the SC anti- tion, interest • 89.9% of patients
TNF user in home in the SC group
groups therapy, and reported either a
• 32.9% males their physi- slight or strong
in the SC cian’s role preference for SC
anti-TNF in treatment route
user group decisions • 71.8% of patients
in the IV group
reported slight or
strong preference
for infusions
• Patients in the IV
group reported
higher effective-
ness scores than
in the SC group,
but lower con-
venience scores
Umar et al. [69], • Germany Prospective 132 • Mean age • Mean disease Conjoint • Topical • Preferences • Closer match 2
2013 • Outpatient cohort 50.2 years duration analysis • Photo- Matching Index— between physi-
• 12/2009– • 61.4% males 18.3 years therapy a measure of cians’ recom-
4/2011 • 28.0% had • Systemic concordance mendations and
PsA • Biologic between attributes patients’ prefer-
• 9.1% had DM that physicians ences associated
• 9.8% had CV prefer compared with greater treat-
disease to attributes that ment satisfaction
• 9.8% had patients prefer • Closely match-
depression (treatment dura- ing physicians’
tion, treatment treatment recom-
frequency, mendations to
treatment cost, patients’ therapeu-
treatment loca- tic preferences is

tion, treatment associated with
delivery method, improvement in
magnitude of multiple domains
beneficial effects, of therapeutic
probability of side satisfaction
effects, probabil-
ity of beneficial
effects, reversibil-
ity of side effects,
and severity of
side effects)
• TSQM measured
patient satisfac-
tion
13
291

292
13
Ito et al. [26], • Japan Cross sectional 34 (in addition, • Mean age NR Study-specific • Topical • Quality-of-life • Type of inflam- 4
2013 • Outpatient 36 patients 57.9 years survey asking • UV questions matory disease
• 1/2008– with AD were • 55.8% males about symp- therapy • Treatment process (psoriasis versus
10/2008 included) toms, quality attributes AD) affects
of life, and • Treatment outpatient prefer-
preference come attributes ences
of treatment • Psoriasis patients
administra- disliked topical
tion and sat- treatment self-
isfaction with applied at home
treatment more than the AD
outcome patients did
were col- • Psoriasis patients
lected were more
satisfied with UV
therapy than AD
patients
• Psoriasis patients
strongly preferred
topical treatment
applied in the
clinic compared
with the AD
patients
Radtke et al. • Germany Cross sectional 1960 • Mean age • Mean dura- PBI—study- • Topical 23 potentially • Patients treated 4
[47], 2013 • Outpatient 51.5 years tion of disease specific • UV therapy relevant treatment with biologics
• 4/2007– • 56.3% males 21.3 years survey asking • Systemic needs regarding had a higher ben-
5/2007 • Mean PASI patients • Sys- the following efit than patients
10.1 before temic + bio- dimensions: using traditional
• 35.6% had therapy about logic • Reduction of systemic agents
nail involve- the benefits • Biologic social impair- • Patients on
ment of treatment • Other ments systemic treat-
personally • Psychological ment had a higher
important impairments patient benefit
to him/her; • Impairments due than those using
during or to therapy local steroids or
after therapy, • Physical impair- other local treat-
patients ments ments

stated • Having confi- • Of all the ultra-
to what dence in healing violet treatments,
extent the PUVA showed
previously- greatest patient
defined aims benefit
of treatment
were met
13
293

294
13
Schaarschmidt • Germany Cross sectional 163 • Mean age • Mean PASI Conjoint • Topical • Treatment process • Treatment prefer- 4
et al. [57], • Outpatient 49.3 years 5.6 analysis • Photo- attributes (loca- ences change over
2013 • 12/2009– • 58.9% males • Mean DLQI therapy tion, frequency, time course and
9/2010 7.6 • Systemic duration, delivery with treatment
• Mean disease • Biologic method, indi- experience
duration vidual cost) • Patients with
17.9 years • Treatment out- longer disease
come attributes duration attach
(probability, greater impor-
magnitude and tance to duration
duration of of benefit versus
benefit; probabil- patients on cur-
ity, severity and rent oral therapy
reversibility of attach greater
side effects) importance to
magnitude of
benefit
• Patients on inject-
able treatment
attach greater
importance to
efficiency and
convenience of
therapies
• Patients receiving
infusions were
more satisfied
than ones on
phototherapy or
topical treatment
Ferwerda et al. • The Nether- Cross sectional 50 (in addition, • Mean age NR Semi- Internet- • Patient approval • Most patients 4
[15], 2013 lands 50 patients 54.4 years structured based CBT of various (78%) indicated
• Outpatient with RA were • 55% males telephone advantages and willingness to
• NR included) interview disadvantages of participate in
online therapy internet-based
• Preference for CBT
the frequency of • Patients endorsed
seeing therapist advantages
face-to-face more often than
• Willingness to disadvantages of
participate in internet-based
online therapy on CBT
a scale • Ease and time
• Importance of saved were highly

various attributes valued
measured on a
scale
Gisondi et al. • Italy Cross sectional 288 • Mean age • Mean PASI Study-specific Balneo- Belief and attitudes • SPA patients 4
[20], 2012 • Outpatient 52.7 years 13.5 in the survey ask- therapy towards tradi- believed that tra-
• 7/2009– in the SPA SPA group ing patients tional therapies ditional therapies
9/2009 group • Mean PASI about their versus alternative are more often
• Mean age 14.7 in the beliefs and treatments for unsafe and inef-
53.0 years hospital group attitudes psoriasis fective compared
in hospital • 70.4% had towards tradi- to alternative
group psoriasis for tional versus therapies, had
• 54.5% males more than alternative less trust in
in the SPA 10 years therapies for physicians, and
group in the SPA psoriasis preferred the
• 64.7% males group nontraditional
in hospital • 54.6% had therapies of bal-
group psoriasis for neotherapy
more than • Fear of adverse
10 years in events is a major
the hospital concern among
group the SPA patients
13
295

296
13
Umar et al. [70], • Germany Cross sectional 163 • Mean age • Mean disease Conjoint • Topical Mean preference • Strong preference 4
2012 • Outpatient 49.3 years duration analysis • Light scores for the against prolonged
• NR • 58.9% males 18.0 years therapy most and least inpatient treat-
• 27.0% had • Systemic preferred treatment and against
PsA • Biologic ment attributes treatment with a
• 8.0% had DM levels lower probability
• 13.5% had of benefit
CV disease • Younger patients
• 12.9% had and women more
depression concerned with
treatment benefit
than older patients
and men
• Preference elicita-
tion should take
into consideration
both preferences
for most and least
preferred thera-
peutic options or
attributes
Schmieder et al. • Germany Cross sectional 163 • Mean age • 27% had PsA Conjoint • Topical • Treatment out- Preferences 4
[59], 2012 • Outpatient 49.3 years • 13.5% car- analysis • Photo- come attributes for treatment
• 12/2009– • 58.9% males diovascular therapy (probability, attributes vary
9/2010 disease • Systemic magnitude and depending on
• 8% diabetes • Biologic duration of comorbidities
• 12.9% depres- benefit; probabil-
sion ity, severity and
reversibility of
side effects)
• Treatment process
attributes (treat-
ment location, fre-
quency, duration,
delivery method,
individual cost)
Umar et al. [68], • Germany Prospective NR NR NR Conjoint • Topical Preference Study described 2
2012 • Outpatient cohort analysis • Light matching index methods for
• NR therapy (measures level of measuring con-
• Systemic matching between cordance between
• Photo- patient-preferred physicians’ and
therapy and physician- patients’ prefer-
recommended ences and for
treatment attrib- assessing the
utes and attribute association of
levels using this concordance
patient-derived with treatment
preference scores outcomes
as a common
denominator)
13
297

298
13
Feuerhahn et al. • Germany Cross-sectional • 2009 patients • Mean age • Mean disease PBI—instru- N/A • Before treat- • PBI showed con- 4
[16], 2012 • Outpatient study and in cross-sec- 51.5 years duration ment ment, patient vergent validity
• 04/2007– longitudinal tional valida- in cross- 21.3 years assessing defines individual regarding QoL,
09/2007 study tion study sectional in cross-sec- individual treatment goals PASI, and two
• 80 patients in study tional study therapy needs and needs from a single questions
the longitudi- • 56.3% males • Mean PASI from the standardized list on treatment
nal validation in cross- 10.1 in cross- perspective • During or after benefit used in the
study sectional sectional of patient, treatment, patients longitudinal study
study study before and rate the degree of • PBI is a suitable
• Mean age • Mean PASI after treat- benefit achieved instrument for
49.3 years in 13.7 in the ment (Score • Patient satisfac- the assessment of
the longitu- longitudinal 0 to 4) tion was measured patient-reported
dinal study study by having patients benefit in the
• 62.4% answer whether treatment of
males in the expectations psoriasis
longitudinal were met, and
study whether treatment
outcome was suf-
ficient
Schaarschmidt • Germany Cross sectional 163 • Ages • 61.3% had Conjoint • Topical RIS for • Location was the 4
et al. [56], • Outpatient 18–35— PASI 0–5 analysis • UV • Treatment process most impor-
2011 • 12/2009– 17.2% • 23.9% had therapy attributes (loca- tant treatment
9/2010 • Ages PASI 5.1–10 • Systemic tion, frequency, attribute, followed
36–49— • 14.7% had • Biologic delivery method, by probability
34.4% PASI > 10 duration, cost) of benefit and
• Ages • Treatment out- method of deliv-
50–64— come attributes ery
31.9% (probability of • RISs for process
• Ages benefit, magni- attributes were
65–80— tude of benefit, higher than for
16.6% duration of ben- outcome attributes
• 58.9% males efit, probability • Older patients
of AEs, revers- were less

ibility of AEs, AE concerned with
severity) probability of
benefit com-
pared to younger
patients
• Patients willing to
trade an increased
risk of adverse
effects for an
increase probabil-
ity and magnitude
of benefit
13
299

300
13
Krenzer et al. • Germany Prospective 1787 (59 com- • Median age • Mean disease PBI—study- N/A • Before treat- • Correlation 2
[30], 2011 • Outpatient cohort pleted PBI) 46 years duration specific ment, patient between DLQI
• 3/2006– • 63.8% male 19 years survey which defines individual and PBI
2/2009 • Mean PASI assessed treatment goals • Skin clearance
25.5 patients’ and needs from a had a positive
• Mean DLQI needs before standardized list and sustainable
13.64 treatment and • During or after impact on all need
• Mean BSA reassessed if treatment, patients dimensions of the
52.4% they had been rate the degree of PBI questionnaire
met after benefit achieved • Successful treat-
treatment ment leads to sus-
tainable treatment
benefit, as shown
by improvement
in PBI and sub-
scales
• Improvement in
skin condition
as measured by
BSA and/or PASI
correlates well
with improve-
ments in HR QoL
in patients with
moderate-to-
severe psoriasis
MacKenzie • Toronto Prospective 63 • Mean age • Mean age Study-specific • Web-based • Ease of use • 42.9% of subjects 4
et al. [36], • Outpatient cohort 53 years of onset of survey ask- question- • Time to comple- preferred the
2011 • NR • 54.0% males psoriasis ing patients naire tion Web-based format
29.0 years about their • Paper- • Worsening of • 19.0% preferred
• Mean age of preferences based joint pain the paper-based
onset of PsA regarding question- • Paper-based format
40.0 years completing naire versus web-based • 33.3% had no
• Mean pso- surveys format preference
riasis disease
duration
20 years
Hauber et al. • United States Cross sectional 415 • Mean age • 63.8% self- Conjoint • Topical Willingness to pay • Patients willing 4
[23], 2011 • Outpatient 54.5 years reported analysis and • Photo- for improvements to pay more for
• NR • 48.5% males disease as contingent therapy in treatment visible lesions
mild or mild- evaluation • Systemic outcomes (willing to pay the
to-moderate • Biologic most for lesions
• 35% self- on the face, then
reported on farm/legs, and
disease as lastly on chest/
moderate to back)
severe • Clear and measur-
able preferences
exist for treatment
outcomes: com-
plete clearance of
mild lesions was
the most impor-
tant outcome
Courtenay et al. • United King- Cross sectional 9 patients with Data for all 42 NR Semi- • Topical Views of patients • Patients believed 4
[10], 2011 dom psoriasis (in patients structured • Topi- on nurse pre- that it was easier
• Outpatient addition, 14 • Mean age interviews cal + sys- scribing, patient and faster to gain
• 3/2009– with AD and 32.4 years temic involvement in access to a nurse
7/2009 19 with acne) • 50% males • Systemic treatment deci- prescriber than a
sions, effect of physician
nurse prescribing • Patient involve-
on medication ment in treatment
adherence, and decisions moti-
satisfaction with vated medication
nurse prescribing adherence
• Patients were
equally satis-
fied with care
provided by the
consultant derma-
tologist compared
with the nurse
prescriber
• Patients thought
that physicians
were more knowl-
edgeable than the
nurses
13
301

whereas patients with cardiovascular disease were highly
PPQ patient preference questionnaire; BSA body surface area; IV intravenous; RA rheumatoid arthritis; anti-TNF anti-tumor necrosis factor; SC subcutaneous; TSQM treatment satisfaction ques-
NR not reported; PsA psoriatic arthritis; PASI psoriasis area and severity index; PGA physician global assessment; PPQ patient preference questionnaire; AD atopic dermatitis; IGA investiga-
tionnaire for medication; DM diabetes mellitus; CV cardiovascular; UV ultraviolet; PBI patient benefit index; PUVA psoralen ultraviolet A; DLQI dermatology life quality index; CBT cognitive
Quality rating scheme for studies and other evidence (1 = properly powered and conducted randomized clinical trial; systematic review with meta-analysis, 2 = well-designed controlled trial
tor’s global assessment; NAPPA-PBI nail assessment in psoriasis and psoriatic arthritis–patient benefit index; NAPSI nail psoriasis severity index; TTAQ topical therapy adherence questionnaire;
without randomization; prospective comparative cohort trial, 3 = case–control studies; retrospective cohort study, 4 = case series with or without intervention; cross-sectional study, 5 = opinion
concerned about the probability of side effects [54, 59].
With the relatively recent introduction of biologic ther-
apy for psoriasis patients [72], it is important to determine
patient preferences for biologics specifically. When we syn-
thesized literature on treatment preferences for biologics
alone, we found that risk of adverse event and probability
of benefit were among top factors affecting patient prefer-
ence [31, 32, 54, 55]. Other important factors affecting treat-
ment preference for patients on biologics included treatment
behavioral therapy; QoL quality of life; RIS relative importance score; AE adverse event; HR QoL health-related quality of life; DCE discrete choice experiment
duration and medication costs, especially among those with

chronic comorbidities such as diabetes and depression [54,
59]. Treatment duration also became more important in
patients on biologics with a greater Psoriasis Area Sever-
ity Index (PASI) score [32] and quality-of-life impairment
[31]. Finally, patients with severe psoriasis on systemic or
biologic therapy considered safety of the medication less
important than other treatment attributes [1, 55].
Process attributes
As mentioned, treatment process attributes include treatment

location, frequency, duration, delivery method, formulation,
and cost of treatment. Among those, the important factors
were treatment location and delivery method [56]. From the
studies that looked at process attributes, one study reported
that patients preferred certain topical treatment formulations,
specifically creams, ointments, and foams, over lotions, gels,
or washes [12]. Age may play a role in topical vehicle prefer-
ence, as younger patients preferred foam and older patients
preferred gel [25]. In other studies, patients preferred peri-
odic injections (either subcutaneous quarterly or intravenous
monthly) over daily oral administration [67], but preferred
once-weekly tablets to periodic injections and daily tablets
when given the option [13]. In addition, patients receiving
injectable drugs attached greater importance to efficiency
and convenience of these injectable medications, compared
to other patients receiving topical therapy, phototherapy, oral
therapy, or infliximab infusions [57]. Psoriasis patients’ pref-
erences for treatment formulation may depend on disease
location. In a non-randomized controlled trial, psoriasis
patients preferred ointment over two gel presentations for
treatment of neck and hairy back and buttocks, but preferred
of respected authorities; case reports)
gel applicator for most plaque locations [27]. Finally, two

studies found that patients preferred online questionnaires
and/or treatment compared to in-person methods [15, 36].
Outcome attributes
Treatment outcome attributes include aspects of treatment

benefit (e.g., probability and magnitude) and side effects
(e.g., severity and reversibility). The most important treat-
ment outcome attributes were probability of treatment
a
13
Table 3 Patient satisfaction in psoriasis treatment
Study Study country; Study design Number of Demographics Psoriasis character- Therapies Satisfaction solic- Outcomes Quality
setting; time psoriasis of psoriasis istics itation methods ratinga
period patients patients
Radtke et al. [48], • Germany Cross sectional 1883 • Median age • Mean disease dura- • Topical therapy Psoriasis Satis- • 23% patients com- 4
2016 • Outpatient 52 years tion was 19 years • Systemic/bio- faction (PsoSat) pletely satisfied with
• NR • 31.3% not • 38.6% suffered from logic therapy Questionnaire current treatment
working psoriasis vulgaris • UV treatment addressing 8 • 82.8% patients moder-
• 32.7% unable for 10–30 years • Other specific items ately to very satisfied
to work for • 35.2% showed rated on a with therapy
the past nail involvement 5-point Likert • 19.1% stated treat-
• 12 months (average 5 fingers scale ment expectations
due to disease involved) were met somehow
• 44.7% reported joint • 39.2% wished for
pain more effective treat-
• 15.2% had con- ments
comitant vascular • 65.7% stated therapy
disorders was not working

• 12.4% had concomi-
tant metabolism and
nutrition disorders
13
303

304
13
Korman et al. • United States Cross sectional 773 • 52.7% mild • Mean disease dura- • Topical therapy Psoriasis Wave • Significantly 4
[29], 2015 • Outpatient psoriasis tion was 19 years • OTC medica- 5 Survey— less patients with
• 2012 • 47.3% moder- • 38.6% suffered from tions Internet-based moderate-to-severe
ate-to-severe psoriasis vulgaris • Biologics survey consist- psoriasis compared
psoriasis for 10–30 years • Oral agents ing of 168 with mild psoriasis
• 56% female • 35.2% showed • Phototherapy questions were satisfied with
• 28.6% joint nail involvement current treatment for
pain (average 5 fingers alleviating symptoms,
• 22.8% depres- involved) providing consistent
sion • 44.7% reported joint control, long-term
• 20.6% osteo- pain cost-effectiveness, and
arthritis • 15.2% had con- fast-acting treatment
comitant vascular • More patients with
disorders moderate-to-severe
• 12.4% had concomi- disease were satisfied
tant metabolism and with current treatment
nutrition disorders for improving QoL
and emotional health
• Patients treated with
biologics were more
satisfied with QoL
improvement and with
treatment response
time
• Patients with topical
therapy were more
satisfied with
symptom alleviation,
consistent control and
response time
Lambert et al. • Belgium, The Prospective 328 • Median age • 24.1% patients suf- Topical therapy TSQM-9 consist- • Patients found gel 2
[34], 2015 Netherlands cohort 44 years fered from psoriasis • Fixed combina- ing of three significantly more
• Outpatient • 57.6% male for > 20 years tion calcipotriol domains: convenient and effec-
• NR • 37.2% patients had plus betametha- effectiveness, tive than ointment
1–5% body surface sone dipropion- convenience, • More patients found
area affected by ate medications and overall sat- gel easier to use, plan
psoriasis • Vitamin D ana- isfaction (over- treatment, and apply
• 27.1% patients had logue all satisfaction compared to ointment
6–10% body surface • Steroids completed at • Patients were more
area affected by • Combination week 52) satisfied with gel
psoriasis steroids and vita- application time than
• 43% patients min D analogues ointment
reported moderate • Other • Patients rated gel
disease severity Systemic treatment significantly greater at

• 16.2% had concomi- • Methotrexate providing benefit than
tant hypertension • Cyclosporine ointment
• Acitretin
• Fumaric acid
• Biologics
• Other
Finch et al. [17], • UK Cross sectional 38 • Median age NR • Topical treat- Satisfaction • Mean “global 4
2015 • Outpatient 43 years ment questionnaire satisfaction” with
• NR • 44.7% male • Phototherapy assessing phototherapy and sys-
• Systemic therapy satisfaction temic treatment were
with topical significantly higher
treatment, than with topical
phototherapy, treatment
and systemic • Satisfaction with
therapy includ- “convenience” of
ing biologics phototherapy and
systemic treatment
were significantly
higher than for topical
treatment
• “Mean total satisfac-
tion” scored for
phototherapy and
systemic therapy were
significantly higher
than for topical treat-
ment
13
305

306
13
Schaarschmidt • Germany Cross sectional 200 • Mean age • Mean PASI 3.4 • Ustekinumab 5-point Likert • Highest TSQM 4
et al. [53], 2015 • Outpatient 50.8 years • Mean DLQI 6.2 • Acitretin scale and score was calcu-
• NR • 57.5% males • Mean psoriasis • Adalimumab TSQM, assess- lated for usteki-
duration 19.9 years • Fumaric acid ing 4 domains: numab, followed by
• 22.5% had PsA ester global satisfac- acitretin,adalimumab,
• Infliximab tion, effective- fumaric acid esters,
• Etanercept ness, adverse infliximab, etanercept,
• Methotrexate events, and and methotrexate
convenience • Global satisfac-
tion was highest for
biologics, followed by
oral systemic agents
Lambert et al. • Belgium and Prospective 156 • Median age Disease duration • Calcipotriol and TSQM-9, Patients preferred gel 2
[33], 2014 The Netherlands cohort 48 years • 9.6%—less than betamethasone assessing two compared to the
• Outpatient • 60.3% males 1 year dipropionate gel domains: effec- ointment in areas of
• NR • 25.6%—1–5 years • Calcipotriol and tiveness and convenience, ease of
• 16.7%—6–10 years betamethasone convenience use, and time spent
• 10.3%—11– dipropionate during application
15 years ointment
• 8.3%—16–20 years
• 29.5%—more than
20 years
van den Reek • The Netherlands Prospective 106 • Mean age • Mean disease dura- • Etanercept TSQM version • High satisfaction rates 2
et al. [73], 2014 • Outpatient cohort 48.2 years tion 20.4 years • Adalimumab II, assessing with biologics, with
• 1/2010–7/2013 • 59% males • 46% biologic-expe- • Ustekinumab 4 domains of improvement in all 4
rienced satisfaction: domains at months
• 54% biologic-inex- effectiveness, 3 and 6 compared to
perienced side effects, baseline
convenience, • Biologic-inexperi-
and global enced patients scored
satisfaction higher in “global
satisfaction” than
biologic-experienced
patients
• “Effectiveness and
convenience” domains
show most room for
improvement
Cazzaniga et al. • Italy Double-blind, 20 • Median age Median disease dura- • Fluorine-syn- Modified VAS • At week 4, global 1
[8], 2014 • Outpatient randomized, 52.5 years tion 4 years thetic fiber socks asking patients satisfaction had a
• 3/2010–9/2011 clinical trial • 40% males • Standard cotton to mark their statistically relevant
socks global satisfac- median score of 32
tion with the (satisfaction towards
socks on a scale fluorine-synthetic
from − 100 to fiber arm)
+ 100 • Patients were more
satisfied with fluorine-
synthetic fabric than
with cotton
Callis Duffin et al. • United States Cross sectional 1182 • Mean age • Median age of pso- • Topicals TSQM version • Biologics, biologic- 4
[7], 2014 • Outpatient 50 years riasis onset 25 years • Methotrexate II, assessing methotrexate combi-
• 2/2010–6/2011 • 51.7% males • Median duration of • Ciclosporin 4 domains: nation, and photo-
psoriasis 19 years • Acitretin effectiveness, therapy had highest
• Adalimumab side effects, median unadjusted
• Etanercept convenience, overall satisfaction
• Infliximab and global scores (83.34), cor-
• Ustekinumab satisfaction responding to “very
• Narrow-band satisfied”
• UVB • Topical therapies and
• Methotrexate acitretin had lowest
with adalimumab unadjusted median
• Methotrexate overall satisfaction
with etanercept scores (66.7), corre-
• Methotrexate- sponding to “satis-
with infliximab fied”
• After fully adjust-
ing for potential
confounders, patients
receiving adali-
mumab, etanercept,
ustekinumab, narrow-
band UVB photother-
apy or adalimumab
with MTX had signifi-
cantly higher adjusted
median scores than
those receiving MTX
monotherapy
13
307

308
13
Jong et al. [28], • Germany Prospective 112 • Plant-based • Plant-based group: • Plant-based oint- Study-specific • 70% of patients were 4
2013 • Outpatient cohort group: mean severity score 1.8 ment telephone sur- very satisfied or
• NR age 38.5 (scale 0–4) • Usual care (topi- vey, assessing satisfied with using
years; 40.9% • Usual care group: cal treatment) patient satisfac- plant-based ointment,
males severity score 2.4 tion (very compared to 60% of
• Usual care (scale 0–4) satisfied, satis- patients with using
group: mean fied, neutral, usual topical treat-
age 43.9 dissatisfied) ment
years; 44.1% • Satisfaction is higher
males with plant-based
homeopathic topical
treatment than with
conventional topical
treatment
Armstrong et al. • United States Cross sectional 5604 • Mean age • 27.9% had psoriatic • Topical corticos- A study-specific 52.3% of patients with 4
[2], 2013 • Outpatient 51.4 years arthritis teroids survey asking psoriasis and 45.5%
• 1/2003–12/2011 • 38.7% males • Mean BMI 28.0 • Non-steroidal about treatment of patients with
topical medica- satisfaction psoriatic arthritis were
tions and reasons for dissatisfied with their
• Calcipotriene treatment dis- treatment
• Betamethasone continuation
dipropionate
• Calcitriol
• Cortisone
• UVB photo-
therapy
• Psoralen-UVA
• Excimer laser
• Methotrexate
• Acitretin
• Cyclosporine
• Etanercept
• Adalimumab
• Alefacept
• Infliximab
• Ustekinumab
• Efalizumab
• Golimumab
van Cranenburgh • The Netherlands Cross sectional 1293 • Mean age • 28.8 years since • Topical therapy Study-specific • Highest satisfaction 4
et al. [72], 2013 • Outpatient 55.9 years diagnosis • Phototherapy satisfaction with biologics
• 8/2010–9/2010 • 53.7% males • 37.3% had 1 or • Oral Agents questionnaire • Lowest with topicals
more of 6 common • Biologics (web-based), Patients rated “treat-
comorbidities assessing ment effectiveness”
• Disease severity 2.5 4 domains: as most important,
(on a scale 1–5) effectiveness, followed by “treat-
side effects, ment safety” and
convenience, “doctor–patient com-
and global munication”
satisfaction • Most room for
improvement: effec-
tiveness of topical
therapy, phototherapy,
and oral agents
(but not biologics),
convenience of topical
treatment, and safety
of all systemics
Franzke et al. • Germany Cross sectional 241 • Mean age Average duration of Examples of each: A study-specific • 54.6% were “rather 4
[18], 2013 • Outpatient 51.6 years disease 19.1 years • Topicals survey asking dissatisfied” or even
• NR • 48.5% males • Conventional about overall “very dissatisfied”
systemics patient satisfac- • 45.3% were “rather
• Biologics tion with previ- satisfied” or “very
• Ultraviolet ous psoriasis satisfied”
therapy treatment (very • Patient satisfaction
• Other unsatisfied, varies and shows need
rather unsatis- for improvement
fied, rather/
moderately
satisfied, very
satisfied)
13
309

310
13
Christophers et al. • France, Ger- Cross sectional 2151 • Topicals: • Mean disease dura- • Topicals Study-specific • Significantly more 4
[9], 2013 many, Italy, mean age 48 tions in each patient • Phototherapy survey asking patients (59%) receiv-
Spain and the years, 63% group • Conventional about overall ing biologics were sat-
United Kingdom males • Topicals: 11 years systemics patient satisfac- isfied with treatment
• Outpatient • Phototherapy: • Phototherapy: • Biologics tion with cur- versus topicals (45%),
• 2007 mean age 46 10 years rent treatment: phototherapy (34%),
years, 57% • Conventional sys- not applicable, or conventional
males temics:13 years completely dis- systemics (50%) (all
• Conventional • Biologics: 13 years satisfied, mod- p < 0.001)
systemics: erately dissatis- • Patients with moder-
mean age 49 fied, slightly ate disease had same
years, 67% satisfied, highly level of satisfaction
males satisfied, and towards both biolog-
• Biologics: completely ics and oral systemic
mean age 47 satisfied treatments
years, 64%
males
Ragnarson Ten- • Denmark, Retrospective 258 • Mean age Mean time since diag- • Topical treat- Study-specific • The highest treat- 4
nvall et al. [49], Finland, and cross sectional 51 years nosis 20 years ments survey asking ment satisfaction, 8.2,
2013 Sweden • 64% males • Systemic drugs for overall was found in patients
• Outpatient • Biologics for less satisfaction on who had been treated
• Sweden: than 12 months a scale from 0 with biologics for 12
7/2008-9/2008 • Biologics for the to 10 months
• Finland: whole 12-month • 6.5 in pts being
1/2009–3/2009 period treated with biologics
• The Nether- and/or oral systemic
lands: 7/2010– treatment for < 12
9/2010 months
• 5.7 in patients being
treated with topical
treatment
Sticherling et al. • Germany Prospective 579 • Mean age • Mean disease dura- Fixed combination Study-specific • Patients benefit from 2
[62], 2013 • Outpatient cohort 51.8 years tion 15.69 years of calcipotriol survey asking convenience and time-
• 3/2011–8/2011 • 55.37% males • Mean PGA 2.98 50 ug/g plus patients about saving of the fixed
• Mean DLQI 8.71 betamethasone 3 satisfac- drug combination
dipropionate tion domains: • Efficacy and toler-
0.5 mg/g effectiveness, ability was assessed as
handling, and “very good” in 85.7%
tolerability of patients, compared
with 27.6% using
prior treatment
Hashimoto et al. • Japan Prospective case 32 • Mean age NR • Topical steroids Study-specific • 53.1% indicated 4
[22], 2012 • Outpatient series 56.16 years • Cyclosporine survey asking dissatisfaction with
• 2005–2007 • 75.0% male patient satisfac- current treatment
tion on a sale • Significant correla-
from 1 to 5 tion between degree
of patient satisfaction
with current treatment
and DLQI
• Prolonged use of topi-
cal steroids may lead
to patient dissatisfac-
tion
Fruhauf et al. • Austria Cross sectional 10 N/A NR N/A Study-specific • Patients were pleased 4
[19], 2012 • Outpatient 20-item with the telederma-
• NR “acceptance” tology service, with
or satisfaction high acceptance rates:
questionnaire 81.0% at week 6 and
82.9% at week 12
• 80.0% of patients
preferred telederma-
tology compared to
in-person consultation
Vender et al. [74], • Canada Multi-center, 246 • Mean age • Mean duration of Etanercept TSQM, assessing Significant improve- 2
2012 • Outpatient phase IV, open 45.5 years psoriasis 21.2 years 4 domains: ment was seen in
• NR label, single • 58.7% males • 43.0% had psoriatic effectiveness, all domains with
arm arthritis diagnosis side effects, etanercept after 3
• Mean BSA 27.6% convenience, months of use, with
• 64.6% had failed and global the exception of the
prior exposure to satisfaction “side-effects” domain
systemic or photo-
therapy
Poulin et al. [44], • Canada Cross sectional 514 • Mean age Self-reported current • Injectable medi- Online study- • 63% receiving 4
2012 • Outpatient 49.7 years severity: 12% very cation specific survey injectables were very
• NR • 49% males mild, 23% mild, • Prescription oral asking patient satisfied
45% moderate, 16% medication satisfaction on • 38% receiving
severe, 4% very • Phototherapy a 4-point scale prescription oral
severe • Prescribed treatment were very
topicals satisfied (compared to
• Over-the-counter less than 1/4 of those
medication receiving topicals or
phototherapy)
13
311

312
13
Paul et al. [42], • Belgium, Randomized, 421 • Mean age • Mean duration of • Etanercept as a • A study-spe- • Mean satisfaction 1
2012 Denmark, multi-center, 46.1 years disease 20.7 years pre-filled syringe cific survey was 8.9 points in the pen
Finland, France, open-label, • 67.4% males • Mean PGA 3.3 • Etanercept as a given asking group and 7.6 points
Germany, phase III study • Mean PASI 17.5 pre-filled pen patients about in the syringe group
Greece, The their satis- • Very satisfied patients
Netherlands, faction with were the oldest and
Norway, Spain, the injection had psoriasis for a
and Sweden device, on a longer duration
• Outpatient 10-point Likert • Higher satisfac-
• 9/2007–4/2009 scale tion with injecting
• In addition, etanercept with a
survey asked pen compared with a
patients about syringe
their perspec- • Factors associated
tive on various with a lower satisfac-
attributes of tion are younger age,
the device, on a anxiety, and depres-
4-point Likert sion
scale
Naldi et al. [41], • Italy, Poland, Randomized, 231 • Plaster group: • Plaster group: mean • Betamethasone A study-specific Patients assessed beta- 1
2011 Switzerland, multi-center, mean age 48.7 duration of psoriasis • Valerate 0.1% survey asking methasone valerate
France phase III years, 62.9% 19.3 years plaster about treatment plasters as signifi-
• Outpatient males • Cream group: mean • Betamethasone satisfaction and cantly more satisfac-
• 4/2006–6/2008 • Cream group: duration of psoria- • Valerate 0.1% ease of use, tory but significantly
mean age 49.5 sis: 16.7 years cream both on as scale less easy to use than
years, 71.1% of 0 to 10, and the cream (student’s t
males about reasons test, both p ≤ 0.005)
for premature
discontinuation
Hjortsberg et al. • Finland and Retrospective 273 • Mean age • Mean time since • Emollients • Study-specific • Patients using emol- 4
[24], 2011 Sweden cross sectional 51 years in diagnosis in Sweden • Topical corticos- survey asking lients were least
• Outpatient Sweden 14 years teroids about satisfac- satisfied
• Sweden: • Mean age • Mean time since • Oral systemic tion with cur- • Patients using biolog-
9/2007–8/2008 53 years in diagnosis in Finland therapy rent treatment ics were most satisfied
• Finland: Finland 18 years • Combination on a scale from with their current
1/2008–1/2009 • 66% males in of oral systemic 0 to 10 and treatment (p ≤ 0.001)
Sweden and biologic reasons for dis- • Patients using oral
• 59% males in therapies satisfaction systemic therapies
Finland • Biologics for less • Chart review were less satisfied
than 12 months than ones using bio-
• Biologics for 12 logics (p ≤ 0.001)
months
Renzi et al. [51], • Italy Cross sectional 240 • 61.7% were • 52.9% had the N/A A study-specific • 27.3% of patients with 4
2011 • Outpatient 50 years disease for less than survey was psoriasis and 28.1% of
• NR of age or 12 years given, asking patients with psoriatic
younger • 46.7% had the dis- patients pre- arthritis want to leave
• 38.3% were ease for 12 or more ferred role in the decisions entirely
more than years decision mak- to their doctor
50 years of ing (six-point • The majority (72.7%
age Likert scale) with psoriasis and
• 67.5% males 71.9% with PsA) want
to be involved in deci-
sion making
• Overall patient
participation and
satisfaction was not

significantly different
between patients with
psoriasis and those
with PsA
Driessen et al. • The Netherlands Retrospective 67 • Age NR Mean PASI at the • Etanercept TSQM version Patients were highly 3
[11], 2010 • Inpatient cohort • 65.7% males start of biologic • Efalizumab II, assessing satisfied with biologic
• 2/2005–2/2009 treatment was 19 • Adalimumab 4 domains of therapies, shown by a
• Infliximab satisfaction: mean TSQM score of
effectiveness, 77.8 (on a scale from
side effects, 0 to 100)
convenience,
and global
satisfaction
13
313

314
13
Poulin et al. [43], • Canada Cross sectional 514 • Mean age of • 65% reported mod- • Over-the-counter Study-specific • Satisfaction with 4
2010 • Outpatient 49.7 years erate, severe, or very therapy survey address- treatment is low
• 12/2007 • 49% males severe disease • Prescribed topi- ing 3 domains: (24%)
• Mean disease cal therapy satisfaction • % of groups reporting
duration more than • Prescribed oral with current being very satisfied:
21 years therapy treatment on a 63% of patients using
• Photo/light scale from 1 to injectables, 38% of
therapy 10, perceived patients using oral
• Prescribed efficacy, and medications, 22%
injectables reasons for dis- using prescription
continuation topical, 21% using
photo/light, and 17%
using over-the-counter
therapy
• 68% reported no
medications work well
for them
• Satisfaction decreased
with increasing dis-
ease severity
NR not reported; PASI psoriasis area severity index; DLQI dermatology life quality index; PsA psoriatic arthritis; TSQM treatment satisfaction questionnaire for medication; VAS visual analogue
scale; UVB ultraviolet B; MTX methotrexate; BMI body mass index; UVA ultraviolet A; PGA physician global assessment; BSA body surface area; RIS relative importance score
a
Quality rating scheme for studies and other evidence (1 = properly powered and conducted randomized clinical trial; systematic review with meta-analysis, 2 = well-designed controlled trial
without randomization; prospective comparative cohort trial, 3 = case–control studies; retrospective cohort study, 4 = case series with or without intervention; cross-sectional study, 5 = opinion
of respected authorities; case reports)
benefit and risk of side effects [31, 32, 54]. From the studies treatment were most satisfied with their current treatment
that looked at treatment outcome attributes, three German (mean treatment satisfaction 8.2/10 at 12 months), followed
studies reported that the highest rated treatment outcome by the traditional oral systemic drugs (mean treatment sat-
attributes were risk of severe and mild adverse events and isfaction 6.4) [24]. Their results revealed that patients using
probability of improvement, specifically probability of emollients were least satisfied with the treatment (mean
90% improvement [31, 32, 54]. Another study corrobo- treatment satisfaction 5.0) [24, 53]. Another study found
rated the finding that patients preferred treatments that did that treatment satisfaction was higher in participants tak-
not increase probability of side effects and also found that ing infusions or injections (52% stated very high treatment
patients preferred treatments with faster onset of visible satisfaction) compared with those on phototherapy (< 8%)
improvement (time until response) and longer symptom- and topical therapy (> 8%) [53]. A U.S. study found that
free periods (duration of benefit) [67]. Reduction of itching biologics, biologic-methotrexate combination, and photo-
was the most important physical goal, followed by reduction therapy resulted in higher satisfaction (mean adjusted overall
in burning and reduction in pain [5, 46]. Psoriasis patients satisfaction score 83/100) compared to topical treatment,
appeared to place greater value to therapies with higher methotrexate, cyclosporine, or acitretin monotherapy (mean
probability of benefit than those with longer duration of adjusted overall satisfaction score 67/100) [7].
benefit [31, 32, 54, 70]. Patients were also more willing to Undertreatment of psoriasis patients could play a direct
accept treatment-related adverse effects to obtain process role in low patient satisfaction. One study demonstrated that
attributes compatible with their personal and professional approximately 30% of patients with moderate psoriasis and
life [56]. Finally, patients placed different values on the vari- 20% of patients with severe psoriasis were treated with topi-
ous treatment outcomes; specifically, they were willing to cal medications alone, with the highest reported reasons as
pay more to treat the lesions on the face, then the arms and “fewer side effects”, “disease severity not serious enough for
legs, and lastly those in the covered areas [23]. other kinds of treatment”, and “doctor would not prescribe
other treatments” [2]. Approximately 50% of patients with
Treatment satisfaction moderate psoriasis and 40% of patients with severe psoriasis
reported dissatisfaction with treatment.
When all treatment modalities were examined, psoriasis Multiple studies found that patients were satisfied with
patients reported low complete satisfaction with the current specific aspects of treatment. For example, satisfaction
treatments [2, 18, 43, 48]. In total, this systematic review with “convenience” was significantly higher in patients on
synthesized 26 studies on patient treatment satisfaction from systemic therapy and phototherapy than patients on topi-
17,472 psoriasis patients. In a cross-sectional study of 5604 cal treatment [17]. Patients on biologics were most satisfied
U.S. psoriasis patients, Armstrong et al. showed that 52.3% with quality-of-life improvement and treatment response
of patients with psoriasis and 45.5% of patients with psori- time [29]. Finally, patients on topical treatment were more
atic arthritis were dissatisfied with their treatment [2]. This satisfied with convenience and effectiveness of gel applica-
study demonstrated the results of National Psoriasis Founda- tion than ointment application [33, 34].
tion (NPF) surveys administered from 2003 to 2011, report- To measure patient treatment satisfaction using validated
ing responses from members with psoriasis and psoriatic instruments, nine studies utilized the Treatment Satisfaction
arthritis. A German study reported that 54.6% of patients Questionnaire for Medication (TSQM), a validated meas-
were “rather dissatisfied” or even “very dissatisfied” with ure that assesses patient satisfaction of medications in four
their treatment, which varied from topical treatment, pho- domains: effectiveness, side effects, convenience, and global
totherapeutic therapy, oral systemic treatments, to biologics satisfaction [7, 11, 33, 53, 63, 69, 73, 74]. Investigators from
[18]. In another study, only 24% of 514 psoriasis patients in The Netherlands using TSQM found that patients receiving
the Canadian population were very satisfied with their cur- etanercept, adalimumab, and ustekinumab reported higher
rent treatment [43]. Finally, a recent study in 2016 demon- satisfaction in all four domains (efficacy, adverse events, con-
strated that only 23% of psoriasis patients were completely venience, and overall satisfaction) at months three and six
satisfied with their current treatment [48]. Sixty-five percent compared to baseline [73]. Furthermore, biologic-inexperi-
of patients stated that therapy was making no progress, and enced psoriasis patients scored higher in the “global satisfac-
40% of patients desired more effective treatments. tion” than biologic-experienced patients [73]. Another study
Although complete satisfaction with overall psoriasis showed that, after controlling for confounders, the highest
treatments was low, a preponderance of studies showed TSQM score was achieved with ustekinumab, followed by
that patients receiving biologics had the highest satisfac- acitretin, adalimumab, fumaric acid esters, infliximab, and
tion over oral systemic treatments, topical treatments and etanercept [53]. In a different study, patients rated “treatment
phototherapy [9, 11, 24, 43, 44, 49, 53, 72, 73]. Specifi- effectiveness” as most important, followed by “treatment
cally, one study demonstrated that patients using biologic safety” and “doctor–patient communication” [63]. Patients
13

expressed that the areas needing most improvement among attributes, such as adverse events [56]. That is, many patients
psoriasis therapies included the following: effectiveness of were willing to accept treatment-related adverse effects to
topical therapy, phototherapy, and oral agents (but not bio- obtain process attributes compatible with their personal and
logics), convenience of topical treatment, and safety of all professional lifestyle. For example, patients were especially
systemic medication (both oral systemic medications and averse to undergoing treatments that are not compatible with
biologics) [72]. lifestyle, such as phototherapy, time-consuming topical ther-
apies, or systemic therapies requiring frequent laboratory
workup. This finding suggests that providers may want to
Discussion initiate conversations with patients on process-related issues,
such as treatment method.
This is among initial systematic reviews to synthesize the For psoriasis patients, probability of improvement using
available data on both patient preferences and patient satis- the drug and fewer adverse events was considered the most
faction in the treatment of psoriasis. This systematic review important treatment outcomes. In addition, reducing lesion
addresses an important gap in the literature by examining severity was highly important to patients, especially when
factors influencing psoriasis patients’ treatment preferences the lesions were in visible areas or areas that cannot be easily
and treatment satisfaction globally. covered. Research showed that psoriasis patients were will-
With regard to treatment preferences, studies showed ing to pay higher out-of-pocket costs for lesion reduction on
that patients’ treatment preferences change over time and the face compared to those on extremities, chest, or the back.
with treatment experience. For instance, patients with longer Because patient satisfaction with treatment is often highly
disease duration (> 10 years) attached significantly greater correlated with patient adherence and consequent treatment
importance to duration of treatment benefit compared to success, it is important to regularly evaluate treatment sat-
patients with shorter disease duration. In addition, those isfaction. Several studies have found that patients ranked
with longer disease duration were less concerned with sever- “treatment effectiveness” as most important in terms of
ity of medication side effects compared with patients with influencing their treatment satisfaction, followed by “treat-
newly diagnosed disease. Treatment preferences were also ment safety” and “doctor–patient communication.” A num-
influenced by disease severity and impact on quality of life. ber of studies have consistently shown that patients treated
For example, patients on biologic therapy with a greater with biologic agents were most satisfied with their treatment,
PASI score and quality-of-life impairment assigned greater followed by traditional oral medication. However, patient
importance to treatment duration. satisfaction over all treatment modalities remained mod-
Overall, patients who have experienced all different cat- est. One possibility of this low satisfaction could be due to
egories of psoriasis therapies and their associated adminis- undertreatment of psoriasis patients, e.g., treating a patient
tration routes preferred biologic therapies over other treat- with severe psoriasis with topical therapy alone. With the
ments. Among patients receiving biologics, they were more availability and high treatment satisfaction of biologics, it
satisfied with quality-of-life improvement and treatment is important for physicians to communicate with patients
response time, but they desired improvement in effectiveness the wide variety of psoriasis treatments available and the
and convenience of treatment. Patients receiving subcutane- implications of each treatment to discuss and agree upon
ous administrations attached greater importance to efficiency the best medication to match the patient’s disease severity.
and convenience of these injectable medications, compared Shared decision making between the provider and the
to other patients receiving topical therapy, phototherapy, patient has been shown to increase medication adherence
oral therapy, or infliximab infusions. Multiple studies found and treatment success. The first step in shared decision-
that patients were satisfied with specific aspects of biologic, making is determining treatment preferences and satisfac-
systemic, phototherapy, and topical treatment. These find- tion from psoriasis patients’ perspective. Recently, decision-
ings will help guide our discussion with patients during the making aids have been created to support the shared decision
shared decision-making process of adjusting treatments. making in dermatology practice [64, 65]. Providing decision
Our study showed that, while heterogeneity in preferences aids will likely lead to decisions that are more reflective of
exists, many psoriasis patients show distinct preferences for patient values [61, 66].
certain treatment attributes. When all treatment modalities The findings of this systematic review are dependent
were considered, the most important treatment attributes on the quality of the primary data. One limitation is that
to patients were treatment location, probability of benefit, patients could be on multiple treatments (systemic and topi-
and method of delivery. For biologic therapy specifically, cal treatments), and several studies assumed that satisfaction
the most important treatment attributes were risk of adverse with current treatment would be determined by the primary,
events and probability of benefit. Notably, some patients systemic treatment. Another limitation is that some studies
placed a greater value on process attributes than outcome used specific preference-elicitation measures, with strictly
13
defined hypothetical treatment alternatives, which may not and patient preferences in choosing treatments for moderate to
be as realistic and or have the same emotional, financial, severe psoriasis. Dermatol Ther (Heidelb) 7(4):463–483
2. Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG
or medical consequences as real-life decisions. Finally, the (2013) Undertreatment, treatment trends, and treatment dissat-
data reported herein may be dependent on geographic loca- isfaction among patients with psoriasis and psoriatic arthritis in
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differences. tion surveys, 2003–2011. JAMA Dermatol 149(10):1180–1185
3. Atkinson MJ, Sinha A, Hass SL, Colman SS, Kumar RN,
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and changed over time among psoriasis patients. When all of treatment satisfaction, the treatment satisfaction question-
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treatment attributes were treatment location, probability chronic disease. Health Qual Life Outcomes 2:12. https://doi.
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therapy specifically, risk of adverse event and probability of Girolomoni G, Gniadecki R, Iversen L, Menter A, Michaelis-
benefit were among the most important treatment attributes. Wittern K, Morita A, Nakagawa H, Reich K (2014) Nail assess-
In addition, demographic and comorbid factors influenced ment in psoriasis and psoriatic arthritis (NAPPA): development
and validation of a tool for assessment of nail psoriasis out-
psoriasis patients’ preferences for certain treatments. Some comes. Br J Dermatol 170(3):591–598
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Acknowledgements We thank Helena Winston for her efforts in the 8. Cazzaniga S, Lo Scocco G, Schincaglia E, Mercuri SR, Chimenti
initiation portion of this project. S, Saraceno R, Naldi L (2014) Double-blind, within-patient, ran-
domized, clinical trial comparing fluorine-synthetic fiber socks
with standard cotton socks in improving plantar psoriasis. J Der-
Author contributions AGF, CJW, and AWA had full access to all of matolog Treat 25(1):26–29
the data in the study and take responsibility for the integrity of the data 9. Christophers E, Segaert S, Milligan G, Molta CT, Boggs R (2013)
and the accuracy of the data analysis. Study concept and design: AWA Clinical improvement and satisfaction with biologic therapy in
and AGF. Acquisition, analysis, and interpretation of data: AWA, AGF, patients with severe plaque psoriasis: results of a European cross-
and CJW. Drafting of the manuscript: AWA, AGF, and CJW. Critical sectional observational study. J Dermatolog Treat 24(3):193–198
revision of the manuscript for intellectual content: AWA, AGF, and 10. Courtenay M, Carey N, Stenner K, Lawton S, Peters J (2011)
CJW. Statistical analysis: N/A. Obtained funding: N/A. Administrative, Patients’ views of nurse prescribing: effects on care, concordance
technical, or material support: N/A. Study supervision: AWA. and medicine taking. Br J Dermatol 164(2):396–401
11. Driessen RJB, Bisschops LA, Adang EMM, Evers AW, van de
Funding There were no funding sources that supported this work. Kerkhof PCM, de Jong E (2010) The economic impact of high-
need psoriasis in daily clinical practice before and after the intro-
Compliance with ethical standards duction of biologics. Br J Dermatol 162(6):1324–1329
12. Eastman WJ, Malahias S, Delconte J, DiBenedetti D (2014)
Assessing attributes of topical vehicles for the treatment of acne,
Conflict of interest The authors have no relevant conflicts of interest atopic dermatitis, and plaque psoriasis. Cutis 94(1):46–53
to declare. AWA serves as investigator and/or consultant to Abbvie, 13. Eliasson L, Bewley AP, Mughal F, Johnston KM, Kuznik A,
Amgen, Janssen, Merck, Novartis, Lilly, Celgene, and Pfizer. Patel C, Lloyd AJ (2017) Evaluation of psoriasis patients’ atti-
tudes toward benefit-risk and therapeutic trade-offs in their
Ethical approval This article does not contain any studies with human choice of treatments. Patient Prefer Adher 11:353–362. https://
participants or animals performed by any of the authors. doi.org/10.2147/PPA.S121838
14. Feldman SR, Horn EJ, Balkrishnan R, Basra MK, Finlay AY,
Informed consent This study did not require formal informed consent. McCoy D, Menter A, van de Kerkhof PC (2008) Psoriasis:
improving adherence to topical therapy. J Am Acad Dermatol
59(6):1009–1016
15. Ferwerda M, Van Beugen S, Van Burik A, Van Middendorp H,
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Florek2018 Article TreatmentPreferencesAndTreatme

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Archives of Dermatological Research (2018) 310:271–319

Treatment preferences and treatment satisfaction among psoriasis

Keywords Psoriasis · Patient preference · Patient participation · Treatment satisfaction

Introduction satisfaction globally. Studies have shown that discordance

Aleksandra G. Florek and Catherine J. Wang contributed equally

Table 1 Conceptual framework of treatment attributes

603 records identified through database searching

400 unique records after 203 duplicate records

400 records screened 333 records eliminated after reviewing abstracts:

13 additional 47 relevant 20 full text articles excluded with reasons:

after 16 weeks improvement,

tion, frequency, • Patients with

response, sustain- medication were

during or after • Physical impair- • At follow-up,

6.8 stated ments QoL impairment

response, sustain- cerned with prob-

ment helped each clinical outcomes

comitant PsA less expensive

treatment loca- tic preferences is

patients ments ments

• Importance of saved were highly

of AEs, revers- were less

whereas patients with cardiovascular disease were highly

duration and medication costs, especially among those with

As mentioned, treatment process attributes include treatment

gel applicator for most plaque locations [27]. Finally, two

Treatment outcome attributes include aspects of treatment

disorders was not working

disease severity Systemic treatment significantly greater at

satisfaction was not

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Table 1 Conceptual framework of treatment attributes