A new study showed that among psoriasis therapies, biologics and a stepwise regimen combining phototherapy with biologics provided the greatest efficacy and quality-of-life gains, although phototherapy alone, especially when done at home, remains cost-effective for payers. Increasing phototherapy usage will require addressing the misalignment of incentives between patients and payers created by insurers’ inconsistent cost-sharing strategies for psoriasis therapies, the authors wrote.

To quantify trade-offs between efficacy, economics, and equity in a psoriasis landscape that includes highly efficacious therapies such as interleukin (IL)-17 and IL-23 inhibitors, investigators, including first author Edward L. Kong, MD-PhD student in the Department of Economics at Harvard Medical School in Boston, simulated clinical outcomes, costs, and net willingness to pay (WTP) for treatments. The study was published online on February 25 in JAMA Dermatology.

Using bimekizumab (Bimzelx) as a representative IL-17 inhibitor, Kong and co-author Elizabeth A. Buzney, MD, relied on randomized controlled trials, meta-analyses, and other previously published data to characterize the first year of treatment for 500,000 simulated adult patients with moderate-to-severe psoriasis on one of three regimens:

• Bimekizumab only
• Narrowband ultraviolet B phototherapy
• Step therapy, wherein patients who failed to achieve at least a 90% reduction in Psoriasis Area and Severity Index (PASI) scores (PASI 90) after 16 weeks of phototherapy received 16 weeks on bimekizumab

At week 32, mean PASI reductions for bimekizumab, step therapy, and phototherapy were 91.6%, 95.2%, and 71.1%, respectively. Biologics and step therapy provided the highest mean first-year quality-adjusted life year (QALY) gains — 0.24 and 0.23, respectively. Nevertheless, mean QALY gains for phototherapy alone (0.18) were cost-effective for payers, especially in the home setting ($6222 mean total billed cost per patient vs $14,760 in-office).

Among payers, biologics had the highest annual mean cost ($84,034) and lowest net WTP (-$59,926), where the mean costs exceeded benefits from the payer perspective. Conversely, patients showed much higher WTP for biologics ($22,107). Patients’ mean out-of-pocket costs for home phototherapy were $1450 alone and $1658 for step therapy. Mean out-of-pocket costs were $2000 for bimekizumab and $5004 for office-based phototherapy (which included copays and travel expenses).

The results, the authors concluded, “suggest that psoriasis treatments provide substantial patient value, with biologics delivering the largest mean gains, phototherapy remaining effective but underused, and step-therapy regimens achieving comparable efficacy at markedly lower cost.”

‘Enormous Efficacy’

Buzney, assistant professor of dermatology at Harvard Medical School, told Medscape Dermatology that she was pleasantly surprised by the “enormous efficacy” of step therapy as opposed to anchoring on a single treatment, with the former approach supporting use of a “therapeutic ladder.” Buzney is also assistant chief medical officer for dermatology and vice chair of quality at the Brigham and Women’s Hospital in Boston.

The sequential regimen may have boosted efficacy, added Kong, because it identified the “rung” that worked best for each simulated patient. Moreover, he said, incorporating the full distribution of outcomes showed that trying phototherapy first can reduce variability in overall outcome distribution.

The study explains why some real-world insurers require patients to fail phototherapy before accessing biologics, Buzney said. But as currently configured, she told Medscape Dermatology, this requirement frustrates patients and providers. “Not everyone has access to phototherapy,” she explained. In a study of phototherapy use among Medicare beneficiaries published in 2018, for example, Buzney and co-authors found that office-based phototherapy facilities cluster in large cities and along the US coasts, making travel impractical for some people.

While home phototherapy is available, said Buzney, cost can be prohibitive without full insurance coverage. Moreover, she said, some people are uncertain if they will feel comfortable performing the treatment at home. Allowing patients to rent booths, as is done throughout much of Europe, would allow patients to evaluate the efficacy of home phototherapy before committing to a more expensive modality such as biologics, she said. 

Joel M. Gelfand, MD, MSCE, told Medscape Dermatology he hopes that the study will “help payers understand that they need to change their policies to make office and home phototherapy more appealing to patients and clinicians.” To increase the number of phototherapy providers, he recommended better reimbursement for office phototherapy, which is generally covered but at low rates. For patients, he recommended eliminating copays for office phototherapy and making home phototherapy easily available by eliminating the lengthy prior authorization process and patient cost sharing. Gelfand is the James J. Leyden, MD, Endowed Professor in Clinical Investigation and medical director of the psoriasis and phototherapy treatment center in the Department of Dermatology at the University of Pennsylvania in Philadelphia. He was not involved with the study but was asked to comment.

Lighting the Way

Fortunately, said Gelfand, results of the Light Treatment Effectiveness study, on which he was the principal investigator, have spurred payers, including Elevance Health (formerly Anthem) and Cigna, to lift phototherapy restrictions. Published in September 2024, the study showed that home-based phototherapy works as well as office-based phototherapy for psoriasis.

As a result of efforts by the National Psoriasis Foundation(NPF) last year, Elevance updated its coverage of home-based phototherapy to include patients with psoriasis for whom topical monotherapy has failed and whose treatment is expected to take at least 3 months. The update establishes similar coverage for other phototherapy-responsive conditions such as eczema and vitiligo. Cigna has also lifted restrictions on home phototherapy for psoriasis and other conditions, according to published accounts.

Mark Lebwohl, MD, dean for clinical therapeutics and chairman emeritus of the Kimberly and Eric J. Waldman Department of Dermatology at Mount Sinai in New York City, told Medscape Dermatology that since the introduction of biologics, phototherapy use has declined, although it is still used for a number of conditions. “Phototherapy never worked great for atopic dermatitis,” he explained. Phototherapy has worked for vitiligo, he added, but much less effectively than current JAK inhibitors.

“In cutaneous lymphoma,” he said, “the drugs we have are not yet quite as far along as they are with some other conditions.” Hence, phototherapy maintains a strong place in treating cutaneous lymphoma, particularly in early stages, noted Lebwohl, who was not involved with the JAMA Dermatology study.

Elevance and Cigna’s coverage changes notwithstanding, Gelfand said, many US payers still do not cover home phototherapy. Even if they do, he said that in his experience, pursuing coverage is “often a lengthy, burdensome process without great communication from the payers.” This situation creates uncertainty among clinicians, many of whom are unaware that home phototherapy may, in fact, be covered by a patient’s insurance, he told Medscape Dermatology.

Gelfand added that education regarding home phototherapy may be limited in dermatology residency programs, making clinicians uncertain about prescribing it. The NPF offers online resources for prescribers seeking such education.

Above all, Gelfand said, the modeling study reminds dermatologists that phototherapy for psoriasis is very safe, effective, and often patient-preferred. “Phototherapy is an excellent strategy for helping patients achieve good clinical responses in an affordable manner,” he added. Such considerations are particularly important, Gelfand said, in settings such as accountable care organizations and integrated health systems, wherein cost containment is crucial because these organizations both provide and pay for care.

Buzney said she hopes that the study reminds practicing dermatologists that, rather than automatically reaching for costly lifelong psoriasis medications, they should continue offering home or in-office phototherapy to the right patients where possible. But US payers’ policies would have to change to facilitate this structure, she told Medscape Dermatology.

Over the years, Buzney said, representatives of the American Academy of Dermatology and other organizations have advocated for payers to change their phototherapy policies but found it difficult. “I would love to have more influence with the insurance companies to make phototherapy possible for our patients,” she said. Buzney said she hopes the study helps spark such discussions.

Kong reported receiving funding from the National Institute on Aging. Buzney reported having no relevant financial interests. 

Gelfand reported serving as a consultant for AbbVie, Arcutis, Alumis, Artax BioPharma, Boehringer Ingelheim, GSK, InmageneBio, Johnson & Johnson, Lilly, LEO Pharma, MoonLake Immunotherapeutics, NeuroDerm, Pfizer, and Oruka Therapeutics and receiving honoraria from Teva. He also reported receiving research grants (from the Trustees of the University of Pennsylvania) from Bristol Myers Squibb and Lilly and receiving payment for psoriasis-related Continuing Medical Education that was supported indirectly by pharmaceutical sponsors.

Lebwohl reported receiving research funds from and being a consultant for AbbVie, Arcutis, Avotres, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant Sciences, Eli Lilly, Johnson & Johnson, Incyte, Oruka Therapeutics, Pfizer, and Sanofi Regeneron. He reported being a researcher for Cara Therapeutics, Clexio Biosciences, Inozyme Pharma, and UCB; and a consultant for Added Health, Almirall, AltruBio, Alumis, Amgen, Apogee Therapeutics, Arcutis, AstraZeneca, Bausch Health, Castle Biosciences, Celltrion, Corevitas, Edesa Biotech, Evommune, Forte Biosciences, Galderma, Genentech, LEO Pharma, Mayne Pharma, Meiji Seika Pharma, Mirium Pharmaceuticals, MoonLake, Revolo Biotherapeutics, Seanergy Dermatology, Strata Skin Sciences, Sun Pharma, Takeda, Trevi, and Verrica.

John Jesitus is a Denver-based freelance medical writer and editor.