We sent an online survey to 309 dermatologists who belong to the Spanish Psoriasis Group (n=89) and/or the Spanish Academy of Dermatology and Venereology (AEDV). The recipients of the survey were considered experts on the treatment of moderate to severe psoriasis and were prescribers of biologics.

The 7 study coordinators agreed on the design of a specific questionnaire that included some open-ended questions and topics for comment (Table 1), for which free-text fields were provided. Most items, however, were answered on a Likert-type scale for expressing preference. These 35 items referred to the sequencing of traditional systemic treatments, criteria governing the decision to start biologic therapy, the advantages of different biologics with respect to a range of attributes, the percentage of patients on continuous treatment, the clinical importance of registry-derived data on the risk of latent tuberculosis reactivation, perception of the safety and expected “survival” of the different biologics, the prevalence and management of joint disease and other comorbidities, and knowledge and perception of the importance of available management guidelines. The comments on open-ended items (written in free-text fields) were grouped by geographic areas (northeast, northwestern, southeastern, central, southern Spain, and the Balearic and Canary Islands) and then evaluated by 7 regional coordinators, who wrote reports organized by subject following a previously designed template. The group then wrote an expert report covering the entire Spanish territory.

We calculated that a sample size of 300 would be required to keep the margin of error in estimation of percentages below 3.5% with a 95% level of confidence and an expected response rate of 70%. Descriptive statistics were prepared, and preferences were compared with the Fisher exact test for categorical variables and analysis of variance (ANOVA) for continuous variables. Subgroup analyses were made for age, sex, level of experience, and geographic area. Only statistically significant and important differences between subgroups are reported. Two-tailed tests of significance (α=.05) were used in all comparisons.

Nine of the 309 dermatologists we emailed did not respond. By geographic location the distribution was as follows: south, 61 (57 responded); central, 60 (56 responded); northwest, 60; northeast, 60; southeastern coastal, 48; Canary Islands, 13; and Balearic Islands, 17 (16 responded). Of the 300 respondents, 170 were men (56.7%) and 130 women. Ages ranged from 29 to 68 years (mean [SD], 43.4 [9.1] years; median [interquartile range], 43 [36–50] years). Men were older on average (mean, 45.2 [8.9] years) than women (41.1 [9.0] years) (P=.0001, t test). All were dermatologists, with experience in the specialty reflected by a median of 15 (8–22) years of practice. Men had a mean of 17.6 (8.9) years of experience in the specialty and women a mean of 14.0 (8.6) years (P=.0005, t test). Only 4 respondents worked mainly outside a national public health system hospital or primary care center.

The respondents reported attending a mean of 468 (186) patients each month (a mean of 55 [34] with psoriasis); the psoriasis is moderate to severe in 39% on average (median, 33.5% [20%–60%]). A median of 62% (30%–90%) of the patients with moderate to severe psoriasis are on a biologic or other systemic therapy. We observed great variation between geographic areas, with percentages ranging from 30% in the Balearic Islands to 81% in the Canary Islands (P=.001, ANOVA). No association with age, sex, or years of experience was evident.

In response to the question about the ideal sequencing of traditional systemic therapies before deciding to start biologic therapy, 45% named UV-B treatments as the first they prescribe, while 22% expressed a preference for starting with methotrexate. Acitretin, ciclosporin, and photochemotherapy (psoralen–UV-A [PUVA]) were named as first treatments by fewer than 15% of the respondents, mainly in relation to their poorer safety profile. The second-line therapy was PUVA for 35% and methotrexate for 20%. Acitretin was named as the third choice by 35%, ciclosporin by 21%, and methotrexate by 20% (Fig. 1).

Figure 1.

Preferred sequencing of traditional systemic therapies. PUVA refers to psoralen–UV-A phototherapy.

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Among male dermatologists, 14.6% reported prescribing only a single systemic treatment before starting a biologic agent; 56.7% prescribed 2 systemic therapies before switching, and 28.7% used more than 2. Among women 3.2% reported prescribing only a single systemic treatment before a biologic agent; 54.4% prescribed 2 systemic therapies before a biologic agent, and 42.4% used more than 2. These differences between men and women were statistically significant (P=.0012; χ2 test), but no association with geographic area or years of experience was detected.

The mean maximum weekly dose of methotrexate indicated by the respondents was 20 (5) mg. The median cumulative dose the respondents thought should not be exceeded was 2g (1.5–3g). The median maximum dosage of ciclosporin reported was 2 (1.5–3) mg/kg/d and the median maximum duration of treatment was 12 (6–24) months. The median maximum dose of acitretin was 50 (35–50) mg. Finally, the median limit on PUVA sessions was 60 (30–200).

When asked which factors were to be considered when deciding on switching from a traditional systemic therapy to a biologic agent, the largest percentage of respondents named toxicity and adverse effects as their main concerns (45%); efficacy was named by the next largest group (38%). Only 16% considered comorbidities when deciding to start biologic therapy. Seventy-three percent of the dermatologists found that 2 years or more passed before patients were switched from traditional to biologic therapies, and 66% felt that this transition period should be shorter.

The respondents assessed the different biologics with respect to several attributes, assigning scores on a scale of 1 to 4, where 1 was the least favorable assessment and 4 the most favorable (Table 2 and Figs. 2–4). The highest score on the different attributes was given to the following biologics: infliximab for rapid onset of action (78%) and short-term efficacy (74%); ustekinumab for mechanism of action (44%), immunogenicity (45%), convenience of administration (73%), and level of patient satisfaction (46%); and etanercept for sustained long-term efficacy (44%), short-term (66%) and long-term (72%) safety profile, clinical experience with the drug (65%), possibility of cyclic (rotational) therapy (71%), possibility of temporary interruption of treatment under certain circumstances such as infections or surgery (76%), efficacy on restarting treatment (65%), lower risk of infection (51%) or cancer (55%), possibility of combination regimens (55%), and stable control of disease (44%). Adalimumab did not receive the highest score for any attribute, but it was considered a second-line therapy by some dermatologists in percentages ranging from 33% to 69% for all attributes except the possibility of rotational regimens (ustekinumab was named by 38%), efficacy on restarting treatment (ustekinumab, 39%), and convenience of administration (etanercept, 55%).

Figure 2.

Perception of attributes related to the mechanism of action and efficacy of biologic agents. The attributes were scored on a scale of 1 to 4, where 1 corresponds to the least favorable opinion and 4 to the most favorable.

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Figure 3.

Perception of attributes related to the safety of biologic agents. Scored on a scale of 1 to 4, where 1 corresponds to the most unfavorable opinion and 4 to the most favorable.

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Figure 4.

Perception of attributes related to the convenience of administration and overall safety of biologic agents. Scored on a scale of 1 to 5, where 1 corresponds to the most unfavorable opinion and 4/5 to the most favorable.

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With respect to other therapies considered safe for combination with biologics, the respondents mentioned topical agents for limited, resistant plaques and seasonal exacerbation and acitretin for hyperkeratotic palmoplantar psoriasis in combination with methotrexate or UV-B phototherapy for the effective control of seasonal exacerbations. They also underlined the importance of avoiding the loss of response over time (especially with infliximab, or, on occasion, when transitioning between biologics).

Seventy-seven percent of the respondents judged that registry data on latent tuberculosis reactivation were of high (42%) or very high (35%) importance in accounting for the favorable profile of etanercept in comparison with tumor necrosis factor antagonists. Nevertheless, only 20% of the dermatologists considered such information to be a decisive factor in their decision to start biologic therapy given that psoriasis patients undergo systematic screening.

All the biologic agents except infliximab were considered generally safe or very safe (scoring 4 or 5 out of 5 points) by percentages of respondents ranging from 52% (ustekinumab) to 88% (adalimumab) (Fig. 4). Etanercept received the highest evaluation from the largest percentage of respondents (scored 5 out of 5 by 48%). This biologic was considered to be associated with lower risk of infection in general and particularly of latent tuberculosis reactivation (scored 4 or 5 out of 5 by 86%). That etanercept is the biologic with which we have accumulated the most experience in patients infected with hepatitis C virus or human immunodeficiency virus was a view expressed by some of the respondents in open text boxes; this opinion was based on their own clinical practice and the available literature. Concerning the concept of drug survival (defined as the duration of continuous treatment without need to withdraw the agent due to primary or secondary failure or adverse events), etanercept once again received the highest score (5 out of 5) from the largest percentage of respondents (33%) (Fig. 5). Etanercept was also the biologic that is routinely prescribed in intermittent courses by the largest group (19.2%), followed by adalimumab (11.6%), ustekinumab (7.6%), and infliximab (2.2%).

Figure 5.

Perception of attributes related to the “survival” of biologic agents. Scored on a scale of 1 to 5, where 1 corresponds to the most unfavorable opinion and 5 to the most favorable. Only options chosen by 10 or more respondents are shown.

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Twenty-eight percent of the surveyed dermatologists estimated that at least 10% of their psoriasis patients have joint involvement, and 60% estimated that figure to be between 10% and 20%. Thirty-seven percent reported routinely examining joints, and 13% said they prescribe therapy for psoriatic arthritis whereas the remaining respondents refer the patient to a rheumatologist for evaluation and treatment. The comorbidities perceived to be most frequent were endocrine disorders (median prevalence, 40% [30%–60%]) and psychological disorders (median prevalence, 40% [20%–60%]). Cardiovascular comorbidity (median prevalence, 20% [10%–30%]) was the next most common. Twenty-nine percent expressed the opinion that comorbidity was a very important factor (scored 5 out of 5) when they were considering transitioning from a traditional systemic to a biologic therapy. A small number of respondents (around 10%) reported prescribing drugs to treat conditions associated with psoriasis.

Finally, 29% of the respondents expressed the belief that clinical guidelines play a very important role (scoring this concept 5 out of 5) in the management of patients. Spanish national guidelines were preferred by 42%, while 22% preferred international guidelines and 20% local recommendations.

According to the respondents’ freely expressed opinions, biologic therapy should be maintained for 24 weeks before efficacy can be evaluated. If the psoriasis area and severity index has not improved by between 50% and 75% (PASI 50–75) by 24 weeks, most would prescribe a traditional systemic therapy in combination with the biologic therapy. A minority of the respondents would switch to another biologic agent. Most believed it is more important to achieve a safe, long-term response than a rapid one of short duration. When response is optimal (PASI 90 or better), many said they would choose to start intermittent therapeutic regimens or lengthen the intervals between doses. Etanercept was named as the biologic most often used in intermittent dosing regimens.

The authors declare that no experiments were performed on humans or animals for this investigation.

The authors declare that they followed their hospital's regulations regarding the publication of patient information and that written informed consent for voluntary participation was obtained for all patients.

The authors declare that no private patient data are disclosed in this article.