KUALA LUMPUR, Nov 4 — Dermatologists have urged the government to expand funding for gold-standard biologics treatment for psoriasis, saying the chronic inflammatory skin disease severely affects quality of life.
Dr Peter Ch’ng, a consultant dermatologist at Gleneagles Hospital, said psoriasis, a long-term illness with no cure, is associated with not just physical health problems like high blood pressure, heart disease, obesity, and diabetes, but also increased risk of depression and anxiety due to discrimination.
“It’s not just a skin condition,” Dr Ch’ng told CodeBlue in an interview. “It’s an auto-immune disease, but affecting the whole body.”
Dr Ch’ng, who is also former Pahang and Sungai Buloh Hospital head of dermatology, revealed his father’s experience with psoriasis since Dr Ch’ng was five or six, noting that the disease affected one’s relationship with their spouse and family.
Psoriasis causes red and itchy scaly patches on the body, mostly on the knees, elbows, and scalp.
“Last time, they’ve been using all these smelly kinds of creams for psoriasis, so definitely your wife will not want to sleep next to you. So my dad had been sleeping in a separate room and he was afraid to carry his kid, hug his kid, because of all the smell, scales on the floor.
“And psoriasis also affects joints. So for him, he had joint deformity, he couldn’t bend his back.”
Treatment for psoriasis comprises topicals (creams applied on the body), phototherapy, and systemic treatment. The latest psoriasis systemic treatment that covers the whole body, said Dr Ch’ng, is injectable biologics that target immune pathways.
Older systemic treatments like methotrexate, acitretin, cyclosporine, he said, are not as effective in clearing skin lesions and may have potential side effects. These side effects include potential hepatitis from the use of methotrexate that may reduce white cell count, as well as the risk of long-term use of acitretin affecting the backbone. Use of these older drugs needs monitoring of white blood cells and liver function, cholesterol function, and blood pressure and the kidney.
Biologics – which have the potential for full skin clearance – generally cost about RM20,000 to RM50,000 a year in private hospitals. The drug is free in government hospitals, but access can be limited. There is still no cure for psoriasis.
Less Than 5% Of Psoriasis Patients Get Biologics
According to a 10-year review of the Malaysian Psoriasis Registry (2007-2016) by Azura Mohd Affandi et al published in 2018 in Dermatology Research and Practice, 15,794 patients aged 18 and above were notified to the Malaysian Psoriasis Registry between July 2007 and December 2016, with men comprising 56.6 per cent. Psoriasis affects about 2 per cent to 3 per cent of the world’s population.
Based on therapy data for 15,635 patients at their first medical visit and 5,701 patients at their last follow-up (six months and above) in Malaysia, between 93.6 per cent and 95.4 per cent were prescribed topical treatment at their first visit and at follow-up respectively, while biologics therapy was given to just 3.3 per cent of patients at their first visit and 2.4 per cent of patients at their last follow-up.
When asked if biologics should be increased in the public sector, Dr Ch’ng said the Ministry of Health (MOH) has a clinical practice guideline dividing patients into mild, moderate, and severe psoriasis. Severe psoriasis affects more than 10 per cent of one’s body surface area and significantly affects quality of life.
“Even severe patients, not everyone can get biologics. They have very limited resources. If you ask me, at least for those very severe patients, get them biologics. That’s the nearest wish list you can reach first,” he said.
According to a 2013 study on psoriasis patients in Malaysia by Min Moon Tang et al published in the International Journal of Dermatology, psoriasis patients treated in Malaysian public hospitals suffered significantly poor quality of life. Their physical and mental health were comparable with patients with heart disease, diabetes, hypertension, or depression.
The study found that the estimated cost of illness for psoriasis was RM1,307.47 per person per year, excluding hospitalisation costs, lower than in other countries. But researchers noted that Malaysian public health care is heavily subsidised by the government.
“Furthermore, certain new treatment options, which are increasingly used in other countries, are not common in the local public sector,” said researchers, urging further exploration of the use of more aggressive treatment options in severely affected patients.
Dr Steven Chow, consultant dermatologist at Pantai Hospital KL, said psoriasis was not a mere cosmetic skin disease, but a chronic relapsing condition associated with other illnesses like psoriatic arthritis and co-morbidities like diabetes, metabolic syndrome, and cardiovascular diseases.
“Let us be very clear. The treatment for psoriasis is not for an aesthetic purpose. Psoriasis is a medical disease and requires medical treatment,” Dr Chow told CodeBlue in an interview.
Wrongly managed, psoriasis can quickly spread and affect the entire body surface area and cause a medical emergency requiring intensive care, a condition called erythrodermic psoriasis that carries a significant mortality rate, he said. Studies also show a higher suicide rate among patients with chronic psoriasis than the normal population.
“I do recall a particular patient in 2005. He was a successful fishmonger in Kepong with a young family. He had psoriasis since his teenage years and was so desperate for a cure for his disease. He died of complications of the treatment administered by a foreigner, a quack posing as a doctor.
“This was a lesson to all that psoriasis can be a serious illness and only properly qualified medical care should be the benchmark,” said Dr Chow.
Biologics Enable Patients To Live A Normal Life
He explained that biologics are special molecules that can target the psoriatic pathology at specific points in the molecular pathway of the disease.
“Biologic treatment is effective and can give remarkable improvement even in cases of chronic recalcitrant disease. Biologics are game-changers in the management for psoriasis today, but are very costly,” Dr Chow said. “It enables patients to live a normal life.”
Older treatments can’t provide the level of recovery compared to biologics, but they are often the first level of care for most psoriasis patients in Malaysia, according to Dr Chow. The standard of care in most countries is to use biologics when patients no longer respond to conventional treatment.
Dr Chow also said with the World Health Organization’s (WHO) 2014 recognition of psoriasis as a serious non-communicable disease, countries can now allocate more from their health budget for the care and treatment of psoriasis patients.
“Patients in countries in North Asia, like Korea and Japan, have better access to the newest treatment modalities,” he said, adding that people with severe psoriasis in Singapore may get financial assistance for treatment.
“From my experience, I am of the opinion that biologic treatment should be used as early as possible in treatment. Biologics are likely to achieve sustainable long-term remission of the disease. In the long run, it is the most cost-effective option in terms of disease control and quality of life improvement for patients,” Dr Chow said.
Associate Prof Dr Norazirah Md Nor, a consultant dermatologist and lecturer at UKM Medical Centre (UKMMC), said government hospitals could still get funding for biologics treatment for psoriasis, but “it is insufficient compared to the proportions of patients requiring biologic therapy.”
She cited the lack of funding available and the inaccurate perception that a skin condition like psoriasis was considered “non-disabling” as among the contributing factors.
“We need to change how we look at the effect of psoriasis on a patient’s life, for example, how their quality of life is affected, loss of income from regular attendance to outpatient visits and treatment, and the complications that the patients may experience as part of the side effects of treatment, particularly in patients with multiple co-morbidities,” Dr Norazirah told CodeBlue.
The dermatologist stressed that psoriasis has been recognised as a systemic disease as it is associated with other conditions like diabetes, high cholesterol, ischemic heart disease, fatty liver, and obesity that affect one’s lifespan.
“The more severe the psoriasis, the higher the risk of these co-morbidities in the patients. Patients may not die of psoriasis, but may do so due to heart attacks and strokes. Treating psoriasis (particularly the severe ones) more aggressively is important in reducing chronic inflammation that is associated with these co-morbidities.”
Dr Norazirah called for more research from university and MOH hospitals on the impact of psoriasis on a patient and to compare the condition to other diseases like ankylosing spondylitis and multiple myeloma that uses biologic therapies, so that the information can be used to support applications for more government funding for psoriasis treatment.
She also suggested implementing social health insurance and a co-pay system between the government and patients for expensive treatment like biologics.
“We need more data on health economics of treating psoriasis with biologics — through research and long term data from our psoriasis registry.”
Nikmatul Azlan, a 47-year-old PR practitioner who has been living with psoriasis for nearly 15 years, said his condition seriously affected his mental health, even if psoriasis “isn’t as serious as cancer”.
“With the gaze of other people, when my skin is red and peeling, wearing long sleeves 24 hours, the worst effect is hypertension and stress,” he told a roundtable on psoriasis, organised by the Galen Centre for Health and Social Policy, on September 22. “As a PR, you have psoriasis, imagine that.”
Nikmatul said he was lucky to have understanding supervisors who allow him to take leave to go for treatment.
“After three months of biologic treatment, my condition recovered. In 2017, they stopped the biologics and [it] flared up after six months. So now, I continue on biologics,” he said.
Nikmatul said biologics are very expensive, with one year of treatment costing the equivalent of a local car, but Hospital Canselor Tuanku Muhriz (HCTM) gave him financial assistance for the treatment through a medical welfare fund.
“Not all patients get help from the welfare fund. That is why, as patients, we ask for incentives for coverage of insurance companies as one of their critical illnesses. Also from medical welfare funds from each hospital.”
Psoriasis Association of Malaysia president Eugene Cross said psoriasis patients in the country can get three months’ worth of medication from a dermatologist for RM5 a visit in public facilities, including for biologics if needed.
However, those staying outside major towns do not have a dermatologist in their hospitals and have no choice but to see a general practitioner (GP) and receive whatever is prescribed.
“Biologics treatment has helped most patients live an almost normal life after the first year of injections,” Eugene told CodeBlue.
“There is no more spending hours in the morning and evening applying your medication. After two years apparently, the skin is almost normal. Wearing short sleeves and shorts are the norm of the day.”