P6973Our experience regarding muscle weakness in the treatment of palmarhyperhidrosis with botulinum toxin type A

Charitomeni Vavouli, Andreas Sygros Hospital, Athens, Greece; Evgenia Balamoti,Andreas Sygros Hospital, Athens, Greece; George Kontochristopoulos, AndreasSygros Hospital, Athens, Greece; Vasiliki Markantoni, Andreas Syggros Hospital,Athens, Greece

Background: Botulinum A toxin (BT/A) is a therapeutic option in focal hyperhidro-sis. Muscle weakness (MW) observed with this therapeutic method is a temporaryside effect. This study aims to show the high incidence of MW and the potentialfactors that appear to affect it.

Methods: During a 2-year period (2008-2010), 474moderate and serious incidents ofpalmar hyperhidrosis were treated at A.Sygros Hospital (312 females and 162 males;14-62 years of age; average age, 29.7 years). Two hundred nine patients reported apositive family history (46.4%). All patients were subjected to starch-iodine test andcryoanalgesia with dichlorotetrafluorethane nebulizer. BT/A was injected intrader-mally at a dose of 100 to 120 U, on average, with insulin syringes of 0.5 mL, at adistance between the points of 2 cm. An injection was performed per finger phalanxand extra injections at the last phalanx and the ulnar border of palm (2.5 U or 0.1 mLper injection site).

Results: The efficiency of the treatment was assessed to be between 75% and100%. Regarding the side effects of the treatment, local pain was reported by 433patients (91.33%) and the majority characterized it as moderate. Twenty-ninepatients exhibited local bruising (6.1%), and 3 patients developed reactivehyperhidrosis (0.6%). MW occurred in 131 cases (27.6%), with half havingreported a family history of focal hyperhidrosis (among patients with MW, 64reported a positive history and 65 reported a negative history). The average ageof appearance of MW is 30 years (26.8 for men and 32 for women). Among thepatients who developed MW, 99 were women and the remaining 32 were men(ie, the incidence of MW for the female population of the study is 31.7% and19.7% for the male population). The onset of symptoms was 5 to 7 days after theinjection, and lasts 2 to 5 weeks.

Conclusion: Hypothetical causes of MW could be include genetic predisposition,gender, age, and diffusion of drug in the underlying muscles, etc. BT/Aconstitutes a reliable therapeutic method for moderate and severe focalhyperhidrosis, improves the quality of life, and is positively evaluated by thepatients. Most patients would repeat the treatment. MW and other side effectsdo not seem to be a restrictive factor, probably because of their transientnature.

AB2

cial support: None identified.

Commer

P7122The versatility of the nasolabial transposition flap in midfacial recon-struction: Our experience

Diogo Matos, MD, Hospital Garcia de Orta, Almada, Portugal; Jo~ao Goul~ao, MD,Hospital Garcia de Orta, Almada, Portugal

The nasolabial flap is an ellipse-shaped transposition flap centered in thenasolabial fold. Technically not very demanding, it has a high viability and afavourable security profile because of its vascularization by the angular arteryand the depth of the surrounding nervous structures. Superiorly based nasola-bial flaps can be used for reconstruction of a wide range of midfacial surgicaldefects. At our dermatology department, during the year of 2010, 78 flaps wereperformed in the setting of reconstructive oncologic surgery of the face, 48 ofthem in the midfacial area. Of these, 20 (42%) were nasolabial flaps, whichwere used mainly for nasal reconstruction (18) but also for infraorbitary defects.This flap was used for all the anatomic subunits of the nose, including thedorsum and the tip, at least once. In addition to its classical usage as atransposition flap, the nasolabial flap was also used as a turn-in and turn-overflap for the nasal ala, and as a tunnelled flap for the tip of the nose. No cases ofloss of viability or major surgical complications were reported. All patients hada follow-up of $ 1 year, and the majority showed a very satisfactory cosmeticand functional outcome, without the need of reintervention. The analysis of ourdata highligts the versatility of the nasolabial flap in the midfacial reconstructionas this flap was used in surgical defects affecting different structures of themidface, particularly the nose. Because of its versatility, viability, and securityprofile, the nasolabial flap is a must-know flap for all the dermatologic surgeons,because it constitutes a very useful and easy to master tool in facialreconstruction.

cial support: None identified.

Commer

J AM ACAD DERMATOL

PD02—PSORIASIS

P6741Access to health care in patients with psoriasis: Data from NationalPsoriasis Foundation survey panels

Tina Bhutani, MD, University of California, San Francisco, Department ofDermatology, San Francisco, CA, United States; April W. Armstrong, MD, MPH,University of California, Davis, Department of Dermatology, Sacramento, CA,United States; Bruce F. Bebo, Jr, PhD, National Psoriasis Foundation, Portland,OR, United States; Jillian W. Wong, MS, University of Utah School of Medicine,Salt Lake City, UT, United States

Background: We aimed to examine the relationship between psoriasis patientcharacteristics and access to care and to determine patients’ out-of-pocket spendingfor psoriasis treatment.

Methods: Thirteen semiannual surveys were conducted among patients withpsoriasis and psoriatic arthritis who are members of the National PsoriasisFoundation from 2003 to 2009 and 2011. The survey participants were identifiedby random sampling of more than 75,000 psoriasis patients. Approximately 400interviews were conducted per survey, with half occurring over the phone and halfonline. The data used in this analysis consist of compiled data from all availablesurvey panels. STATA computer statistical package, version 12, was used for allstatistical analysis. Main outcome measures included the number and type ofphysicians seen in the last 2 years, and out-of-pocket health care expenses weremeasured.

Results: Among 5,604 patients with psoriasis and psoriatic arthritis, 92% of psoriasispatients had seen at least 1 physician in 2 years. Compared tomales, female psoriasispatients were 1.47 times more likely to seek care (adjusted odds ratio [OR], 1.47;95% confidence interval [CI], 1.18-1.83). Patients with private insurance andMedicare were more likely to seek care compared to uninsured patients (adjustedOR, 3.02; 95% CI, 2.23-4.08; adjusted OR, 2.85; 95% CI, 1.91-4.24, respectively).Among psoriasis patients seeking care, 78% were seeing specialists; 22% obtainedcare from primary care physicians. Primary reasons for not seeking treatmentsincluded giving up on disease treatment (28%) and prohibitive cost (21%).Compared to patients with mild disease, patients with severe psoriasis were morelikely to seek a specialist for care (adjusted OR, 1.64; 95% CI, 1.37-1.98). Patientsspent an average of $2528 out-of-pocket per year for psoriasis care.

Conclusions: Nearly a quarter of patients seek psoriasis care from primary careproviders, and insurance status affects care-seeking patterns. Giving up ontreatment and prohibitive costs remain primary reasons for not seeking care.

cial support: None identified.

Commer

P6834Cost-effectiveness of biologic therapies for plaque psoriasis: A systematicreview

Christine Ahn, Wake Forest School of Medicine, Winston-Salem, NC, UnitedStates; Cheryl Gustafson, MD, Wake Forest School of Medicine, Winston-Salem,NC, United States; Scott Davis, Wake Forest School of Medicine, Winston-Salem,NC, United States; Steven Feldman, MD, PhD, Wake Forest School of Medicine,Winston-Salem, NC, United States

Background: The use of biologic agents has changed the therapeutic management ofsevere plaque psoriasis. In addition to clinical efficacy, biologics are associated withhigher costs than traditional therapy. Therefore, when assessing the clinical efficacyof biologic agents, it is important to consider their cost-effectiveness.

Purpose: To determine the cost-effectiveness of biologic agents, measured by thecost per patient achieving a minimally important difference in the Dermatology LifeQuality Index (MID DLQI) and cost per patient achieving a 75% improvement in thePsoriasis Area Severity Index (PASI-75).

Methods: A PubMed literature search was conducted to identify randomizedplacebo-controlled clinical trials describing the efficacy of FDA-approved biologictherapies. Cost-effectiveness was determined by the cost per patient achieving aMID DLQI and PASI-75 after 12 weeks of treatment. A sensitivity analysis wasperformed to compare cost-effectiveness ratios. Treatment paradigms were extrap-olated to estimate cost-effectiveness of 1 year of treatment.

Results: Twenty-seven trials evaluating adalimumab, alefacept, etanercept, inflix-imab, and ustekinumab were included in this study. Infliximab 3mg/kg IV (weeks 0,2, and 6) was the most cost-effective agent achieving a MID DLQI at 12 weeks,followed by etanercept 25 mg SQ once weekly and infliximab 5 mg/kg IV. The mostcost-effective agents achieving a PASI-75 were infliximab 3 mg/kg IV andadalimumab 40 mg SQ every other week (with or without 80-mg loading dose).The annual cost of biologic treatment ranged from $6800 for low dose alefacept to$56,000 for high dose ustekinumab. Infliximab 3 mg/kg IV had the lowest annualcost per patient achieving both a MID DLQI and PASI-75. The least cost-effectivetreatment paradigm for DLQI and PASI outcomes was alefacept.

Limitations: This study is limited by the lack of head-to-head trials that determineaccurate relative efficacies. In addition, this study did not incorporate indirect costsor variation in costs caused by insurance company contracting.

Conclusion: Infliximab 3 mg/kg IV had the most favorable cost-effectiveness profile,with the lowest cost per patient achieving both a MID DLQI and PASI-75. Otherbiologic agents foundd small differences in cost-effectiveness, likely to be over-whelmed by individual variation, insurance company price contracting, and theuncertainty inherent with the lack of head-to-head trials to determine relativeefficacy.

cial support: None identified.

Commer

APRIL 2013