Clinical Severity of Psoriasis in Last 20 Years of PUVA Study

Nijsten, Tamar MD, PhD
Looman, Caspar W. N. PhD
Stern, Robert S. MD

Departments of Dermatology (Dr Nijsten) and Public Health (Dr Looman), Erasmus Medical Center, Rotterdam, the Netherlands; and Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr Stern).

Correspondence: Robert S. Stern, MD, Department of Dermatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 ([email protected]).

Author Contributions: Dr Stern is the principal investigator of the PUVA Follow-up Study. Study concept and design: Nijsten and Stern. Acquisition of data: Stern. Analysis and interpretation of data: Nijsten, Looman, and Stern. Drafting of the manuscript: Nijsten. Critical revision of the manuscript for important intellectual content: Nijsten, Looman, and Stern. Statistical analysis: Nijsten and Looman. Obtained funding: Stern. Administrative, technical, and material support: Nijsten and Stern. Study supervision: Stern.

Financial Disclosure: None reported.

Funding/Support: This study was funded in part by Public Health Service contract N01-AR-0-2246 from the National Health Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Department of Health and Human Services.

Additional Contributions: We thank the patients and principal investigators of the multicenter PUVA Follow-up Study for their participation; M. Cosmos and S. Paquette for collecting and managing data for this project; D. Spiegelman for input on data analysis; and Christopher Jackson, PhD, Imperial College, London, England, for providing access to Markov modeling software. The following institutions and investigators have participated in the recruitment and follow-up of patients in this study: Stanford University School of Medicine, Stanford, California (E. Bauer and E. Abel); University of California at San Francisco (J. H. Epstein and J. Koo); Baylor College of Medicine, Houston, Texas (J. Wolf); Washington Hospital Center, Washington, DC (T. P. Nigra); University of Michigan Medical School, Ann Arbor (T. F. Anderson); Columbia University College of Physicians and Surgeons, New York, New York (J. Prystowsky and M. J. Stiller); Mayo Graduate School of Medicine, Rochester, Minnesota (M. McEvoy); University of Miami Medical School, Miami, Florida (J. R. Taylor); Mt Sinai Medical Center, Miami Beach, Florida (N. Zaias); Temple University School of Medicine, Philadelphia, Pennsylvania (F. Urbach); Beth Israel Deaconess Medical Center, Boston, Massachusetts (R. S. Stern); Dartmouth Medical School, Hanover, New Hampshire (R. D. Baughman); Yale University of Medicine, New Haven, Connecticut (I. M. Braverman); Duke University Medical Center, Durham, North Carolina (J. Murray); University of Pennsylvania Hospitals, Phildelphia (V. P. Werth); and Massachusetts General Hospital, Boston (T. B. Fitzpatrick [deceased], J. Parrish, C. Taylor, and A. J. Sober).

Accepted for Publication: February 25, 2007.

Archives of Dermatology 143(9):p 1113-1121, September 2007.

Objective

To assess the severity of psoriasis over time.

Design

We analyzed the results of structured dermatologic examinations administered over a 20-year period beginning 10 years after study enrollment.

Setting

The PUVA [psoralen–UV-A] Follow-up Study, which is a prospective cohort study.

Patients

The analyses were restricted to 815 patients (83.2% of those eligible) who underwent at least 2 of 4 possible examinations between 1985 and 2005.

Main Outcome Measure

A 4-point physician global assessment (PGA).

Results

The distribution of the PGA levels in the study group did not change significantly over time, except that in 2005 more patients had no psoriasis compared with patients who underwent examinations in the previous study years (9.6% vs < 5.1%, P < .03). The PGA level changed more than 1 level between examinations in only 14% of patients. Multistate Markov models estimated that patients had a likelihood of about 80% to remain at the same PGA level 1 year later. After 10 years, this likelihood varied between 19% and 53%, depending on the PGA level. Except for patients who were clear of disease at baseline, on average patients had about 1 year without psoriasis over 20 years. On average, individuals with moderate to severe disease remained at these levels for 11 or more years.

Conclusion

Three decades after a large and diverse group of patients sought a cure for their psoriasis, consistent control of their psoriasis often had not been achieved.