Biologics Can Significantly Improve Dermatology Life Quality Index (DLQI) in Psoriatic Patients: A Systematic Review

Figures & data

Figure 1 Flow diagram of study selection.

Table 1 Critical Appraisal of Included Cohort Studies

Study	Were the Different Groups Similar and Recruited from the Same Population?	Were the Exposures Measured Similarly to Assign People to Different Exposed Groups?	Was the Exposure Measured in a Valid and Reliable Way?	Were Confounding Factors Identified?	Were Strategies to Deal with Confounding Factors Stated?	Were the Outcomes Measured in a Valid and Reliable Way?	Was the Follow-Up Time Reported and Sufficient to Be Long Enough for Outcomes to Occur?	Was Follow-Up Complete, and if not, Were the Reasons to Loss to Follow-Up Described and Explored?	Was Appropriate Statistical Analysis Used?
Ahn et al^Citation6	Yes	Yes	Yes	No	No	Yes	Yes	Unclear	Yes
Reich K et al^Citation12	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes
Iskandar et al^Citation14	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes
Frieder et al^Citation9	No	Yes	Yes	No	No	Yes	Yes	Unclear	Yes
Solberg et al^Citation16	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes

Table 2 Critical Appraisal of Included Cross Sectional Studies

Study	Were the Criteria for Inclusion in the Sample Clearly Defined?	Were the Study Subjects and the Setting Described in Detail?	Was the Exposure Measured in a Valid and Reliable Way?	Were Objective, Standard Criteria Used for Measurement of the Condition?	Were Confounding Factors Identified?	Were Strategies to Deal with Confounding Factors Stated?	Were the Outcomes Measured in a Valid and Reliable Way?	Was Appropriate Statistical Analysis Used?
Radtke et al^Citation10	No	Yes	Yes	Yes	Yes	No	Yes	Yes
Fernández-Torres et al^Citation11	Yes	Yes	Yes	Yes	No	No	Yes	Yes
Norris et al^Citation15	Yes	Yes	Yes	Yes	No	No	Yes	Yes

Table 3 Critical Appraisal of Included Case Series

Study	Were There Clear Criteria for Inclusion in the Case Series?	Was the Condition Measured in a Standard, Reliable Way for All Participants Included in the Case Series?	Were Valid Methods Used for Identification of the Condition for All Participants Included in the Case Series?	Did the Case Series Have Consecutive Inclusion of Participants?	Did the Case Series Have Complete Inclusion of Participants?	Was There Clear Reporting of the Demographics of the Participants in the Study?	Was There Clear Reporting of Clinical Information of the Participants?	Were the Outcomes or Follow-Up Results of Cases Clearly Reported?	Was There Clear Reporting of the Presenting Site(s)/Clinic(s) Demographic Information?	Was Statistical Analysis Appropriate?
Buffiere-Morgado et al^Citation13	Yes	Yes	Yes	No	No	Yes	Yes	Yes	No	Yes

Table 4 Characteristics of Included Studies

Author, Year	Study Design	N (% Male)	Mean Age (SD)	Follow Up	Mean Duration of Psoriasis (Years)	Therapy Intervention	Mean Baseline DLQI
Ahn et al, 2013.^Citation6	Cohort	Adalimumab: 1799 (67.7)	Adalimumab: 44.0	12 weeks	Adalimumab: 17.5	Adalimumab	Adalimumab: 11.4
		Alefacept: 1186 (65.1)	Alefacept: 45.1		Alefacept: 19.1	Alefacept	Alefacept: 10.7
		Etanercept: 2107 (66.0)	Etanercept: 45.3		Etanercept: 19.3	Etanercept	Etanercept: 12.2
		Infliximab: 1462 (68.1)	Infliximab: 43.8		Infliximab: 18.2	Infliximab	Infliximab: 12.8
		Ustekinumab: 1230 (69.6)	Ustekinumab: 45.6		Ustekinumab: 19.6	Ustekinumab	Ustekinumab: 12.2
Radtke et al, 2013.^Citation10	Cross sectional	Biologics: 171	-	Inapplicable	-	Biologics	Inapplicable
		Conventional systemic therapy: 387			-	Conventional systemic therapy	Inapplicable
Fernández-Torres et al, 2014.^Citation11	Cross sectional	Biologics: 66	-	Inapplicable	-	Biologics	Inapplicable
		Conventional systemic therapy: 119			-	Conventional systemic therapy	Inapplicable
Reich K et al, 2015.^Citation12	Cohort	Biologics: 634 (63.7)	Biologics: 48.0	Inapplicable	Biologics: 21.9	Biologics	Inapplicable
		Systemic therapy: 1584 (58.9)	Systemic therapy: 46.8		Systemic therapy: 16.9	Systemic therapy	Inapplicable
Buffiere-Morgado et al, 2017.^Citation13	Case series	15 (80.0)	51.9	4 months	-	Adalimumab therapy	15.4
Iskandar et al, 2017.^Citation14	Cohort	Etanercept: 517	Etanercept: 45.1 (± 12.1)	12 months	Etanercept: 22.9 (SD: ± 12.1)	Etanercept	Etanercept: Median 18 (IQR: 13–24)
		Adalimumab: 1239	Adalimumab: 44.8 (± 12.4)		Adalimumab: 22.3 (SD: ± 12.1)	Adalimumab	Adalimumab: Median 18 (IQR: 13–23)
		Ustekinumab: 396	Ustekinumab: 46.7 (± 12.3)		Ustekinumab: 22.0 (SD: ± 12.1)	Ustekinumab	Ustekinumab: Median 19 (IQR: 13–24)
Norris et al, 2017.^Citation15	Cross sectional	Adalimumab: 35	-	24 weeks	-	Adalimumab	-
		Etanercept: 7			-	Etanercept	-
		Infliximab: 5			-	Infliximab	-
		Secukinumab: 3			-	Secekinumab	-
		Ustekinimab: 59			-	Ustekinimab	-
Frieder et al, 2018.^Citation9	Cohort	Adalimumab: 40 mg EOW vs PBO: 1212	-	Adalimumab: 40 mg EOW vs PBO: 16 weeks	-	Adalimumab: 40 mg weekly or EOW vs PBO	Inapplicable
		Infliximab: IV 5 mg/kg vs PBO: 378		Infliximab: IV 5 mg/kg vs PBO: 12 weeks	-	Infliximab: IV 5 mg/kg vs PBO	Inapplicable
		Etanercept: - 50 mg weekly, TW vs PBO: 583 - 25 mg weekly, 50 mg weekly, 50 mg TW vs PBO: 652		Etanercept: - 50 mg weekly, TW vs PBO: 12 weeks - 25 mg weekly, 50 mg weekly, 50 mg TW vs PBO: 12 weeks	-	Etanercept: - 50 mg weekly, TW vs PBO - 25 mg weekly, 50 mg weekly, 50 mg TW vs PBO	Inapplicable
		Ustekinumab: - 45 mg, 90 mg vs PBO (PHOENIX-1 study): 766 - 45 mg or 90 mg vs PBO (PHOENIX-2 study): 1230		Ustekinumab: - 45 mg, 90 mg vs PBO (PHOENIX-1 study): 12 weeks - 45 mg or 90 mg vs PBO (PHOENIX-2 study): 12 weeks	-	Ustekinumab: - 45 mg, 90 mg vs PBO (PHOENIX-1 study) - 45 mg or 90 mg vs PBO (PHOENIX-2 study)	Inapplicable
		Secukinumab: - 150 mg or 300 mg vs PBO (ERASURE study): 738 - 150 mg or 300 mg vs PBO (FIXTURE study): 1306		Secukinumab: - 150 mg or 300 mg vs PBO (ERASURE study): 12 weeks - 150 mg or 300 mg vs PBO (FIXTURE study): 12 weeks	-	Secukinumab: - 150 mg or 300 mg vs PBO (ERASURE study) - 150 mg or 300 mg vs PBO (FIXTURE study)	Inapplicable
Solberg et al, 2018.^Citation16	Cohort	Infliximab: 10 (50.0)	Infliximab: 41.40 (16.56)	16 weeks	-	Infliximab	Infliximab: 16.20 (SD: 6.37)
		Ustekinumab: 10 (60.0)	Ustekinumab: 38.20 (16.48)		-	Ustekinumab	Ustekinumab: 11.80 (SD: 6.75)
		Secukinumab: 10 (90.0)	Secukinumab: 50.40 (9.96)		-	Secukinumab	Secukinumab: 13.00 (SD: 8.01)
		Etanercept: 10 (80.0)	Etanercept: 38.30 (14.55)		-	Etanercept	Etanercept: 17.70 (SD: 5.77)

Abbreviations: EOW, every other week; IV, intravenously; SD, standard deviation; PBO, placebo; IQR, interquartile range; TW, twice weekly.

Table 5 Results of Included Studies

Author, Year	Outcome Measurement	Results
Ahn et al, 2013.^Citation6	Mean unit DLQI improvement after 12 weeks (95% CI or SD in studies)	Adalimumab - 40 mg SQ once weekly after 80 mg loading dose: 11.5 (95% CI 9.4–13.6) - 40 mg SQ EOW after 80 mg loading dose: 8.6 (95% CI 7.8–9.4)
		Alefacept - 0.025 mg/kg IM once weekly: 4.0 (0.9) - 0.075 mg/kg IM once weekly: 4.4 (0.9) - 0.150 mg/kg IM once weekly: 3.2 (0.9) - 10 mg IM once weekly: 3.8 (NR) - 15 mg IM once weekly: 4.9 (NR) - Placebo: 2.4 (NR)
		Etanercept - 25 mg SQ once weekly: 5.8 (NR) - 50 mg SQ once weekly: 7.4 (NR) - 25 mg SQ twice weekly: 6.5 (NR) - 50 mg SQ twice weekly: 7.9 (NR)
		Infliximab - 3 mg/kg IV for 3 infusions: 9.3 (7.0) - 5 mg/kg IV for 3 infusions: 10.5 (7.1)
		Ustekinumab - 45 mg SQ twice: 9.0 (7.1) - 90 mg SQ twice: 9.5 (6.6)
Radtke et al, 2013.^Citation10	Mean DLQI of 0+ −30 (SD)	Biologics: 6.5 (6.7)
		Conventional systemic therapy: 7.2 (6.9)
Fernández-Torres et al, 2014.^Citation11	Logistic regression model to predict Dermatology Life Quality Index impairment adjusted for biologic vs conventional systemic therapy	B (constant): 0.809 P-value: 0.053, OR: 2.245, 95% CI: 0.991–5.088
Reich K et al, 2015.^Citation12	Mean DLQI of 0+ −30 (SD)	Biologics: 11.6 (7.5)
		Systemic therapy: 10.9 (6.8)
Buffiere-Morgado et al, 2017.^Citation13	Mean DLQI after four months	2.13 (p < 0.01)
Iskandar et al, 2017.^Citation14	Median DLQI (IQR) after 12 months	Etanercept: 3 (1–9) (p < 0001)
		Adalimumab: 1 (0–6) (p < 0001)
		Ustekinumab: 1 (0–6) (p < 0001)
Norris et al, 2017.^Citation15	Change in DLQI score at week 24 (95% CI)	Adalimumab: −3.68 (−7.19 to −0.17) (p 0.040)
		Etanercept: −2.99 (−8.06 to 2.09) (p 0.245)
		Infliximab: −10.94 (−16.67 to −5.22) (p < 0.001)
		Secukinumab: −8.96 (−15.53 to −1.85) (p 0.013)
		Ustekinimab: −7.51 (−10.99 to −4.02) (p < 0.001)
Frieder et al, 2018.^Citation9	Adalimumab: Mean change DLQI	Adalimumab: 40 mg EOW: −8.4 vs PBO: −1.9 (p < 0.001)
	Infliximab: Mean DLQI score improvement	Infliximab: IV 5 mg/kg vs PBO: INF: 10.3 vs PBO: 0.4 (p < 0.001)
	Etanercept: % patients with clinically meaningful DLQI score (≥5-points improvement)	Etanercept: - 50 mg weekly: 72%, TW: 77% vs PBO: 26% (p < 0.0001) - 25 mg: 50%, 50 mg weekly: 54%; 50 mg TW: 63% vs PBO: 28% (p < 0.0001)
	Ustekinumab:  45 mg, 90 mg vs PBO (PHOENIX-1 study): % patients with normalized DLQI score (≤ 1)  45 mg or 90 mg vs PBO (PHOENIX-2 study): Mean improvement in DLQI score	Ustekinumab: - (PHOENIX-1 study) 45 mg: 53.2%, 90 mg: 52.4% vs PBO: 6.0% (p < 0.001) - (PHOENIX-2 study) 45 mg: −9.3, 90 mg: −10.0 vs PBO: −0.5 (p < 0.001)
	Secukinumab:  Absolute change in DLQI score	Secukinumab: - (ERASURE study) 300 mg: −11.4; 150 mg: −10.1 vs PBO: −1.1 (p < 0.001) - (FIXTURE study) 300 mg: −10.4; 150 mg: −9.7; vs PBO: −1.9 (p < 0.001)
Solberg et al, 2018.^Citation16	DLQI at follow up (SD)	Infliximab: 2.20 (2.30) (p ≤ 0.01)
		Ustekinumab: 4.13 (2.96) (p ≤ 0.05)
		Secukinumab: 4.40 (4.65) (p ≤ 0.01)
		Etanercept: 5.20 (3.93) (p ≤ 0.01)

Abbreviations: SQ, subcutaneously; IM, intramuscularly; NR, not reported; CI, confidence interval.

Table 6 Results per Outcome

Outcome	Studies	Results per Study: Mean DLQI Score Improvement*
Adalimumab therapy with ≥5-points DLQI improvement	Ahn et al, 2013.	40 mg SQ once weekly after 80-mg loading dose: 11.5 (95% CI 9.4–13.6)
		40 mg SQ EOW after 80-mg loading dose: 8.6 (95% CI 7.8–9.4)
	Buffiere-Morgado et al, 2017.	13.27 (p < 0.01)
	Iskandar et al, 2017.	Median 14 [IQR: 8 to 19] (p < 0001)
	Frieder et al, 2018.	40 mg EOW: 8.4 (p < 0.001)
Etanercept therapy with ≥5-points DLQI improvement	Ahn et al, 2013.	25 mg SQ once weekly: 5.8
		50 mg SQ once weekly: 7.4
		25 mg SQ twice weekly: 6.5
		50 mg SQ twice weekly: 7.9
	Iskandar et al, 2017.	Median 11 [IQR: 6 to 9] (p < 0001)
	Frieder et al, 2018.	50 mg weekly: 72% patients; TW: 77% patients (p < 0.0001)
		25 mg weekly: 50% patients; 50 mg weekly: 54% patients; 50 mg TW: 63% patients (p < 0.0001)
	Solberg et al, 2018.	12.50 (p ≤ 0.01)
Infliximab therapy with ≥5-points DLQI improvement	Ahn et al, 2013.	3 mg/kg IV for 3 infusions: 9.3 (SD 7.0)
		5 mg/kg IV for 3 infusions: 10.5 (SD 7.1)
	Norris et al, 2017.	10.94 (95% CI: 5.22 to 16.67) (p < 0.001)
	Frieder et al, 2018.	IV 5 mg/kg: 10.3 (p < 0.001)
	Solberg et al, 2018.	14.00 (p ≤ 0.01)
Ustekinumab therapy with ≥5-points DLQI improvement	Ahn et al, 2013.	45 mg SQ twice: 9.0 (SD 7.1)
		90 mg SQ twice: 9.5 (SD 6.6)
	Iskandar et al, 2017.	Median 14 [IQR: 7 to 20] (p < 0001)
	Norris et al, 2017.	7.51 (95% CI: 4.02 to 10.99) (p < 0.001)
	Frieder et al, 2018.	(PHOENIX-2 study) 45 mg: 9.3; 90 mg: 10.0 (p < 0.001)
	Solberg et al, 2018.	7.67 (p ≤ 0.05)
Secukinumab therapy with ≥5-points DLQI improvement	Norris et al, 2017.	8.96 (95% CI: 1.85 to 15.53) (p 0.013)
	Frieder et al, 2018.	(ERASURE study) 300 mg: 11.4; 150 mg: 10.1 (p < 0.001)
		(FIXTURE study) 300 mg: 10.4; 150 mg: 9.7 (p < 0.001)
	Solberg et al, 2018.	8.60 (p ≤ 0.01)
DLQI improvement better with biologics than with systemic therapy	Radtke et al, 2013.	DLQI of patients with biologics is 0.7 points better than of patients with systemic therapy.
	Fernández-Torres et al, 2014.	Quality Index impairment adjusted for biologic vs conventional systemic therapy, B (constant): 0.809 (p 0.053)

Note: *For other results this will be indicated in the table.

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