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Summary   Background  Pyoderma gangrenosum ( PG ) is a painful, ulcerating skin disease with poor evidence for management. Prednisolone and ciclosporin are the most commonly used treatments, although not previously compared within a randomized controlled trial ( RCT ).    Objectives  To compare the cost‐effectiveness of ciclosporin and prednisolone‐initiated treatment for patients with  PG .    Methods  Quality of life (QoL, EuroQoL five dimensions three level questionnaire,  EQ ‐5D‐3L) and resource data were collected as part of the  STOP GAP  trial: a multicentre, parallel‐group, observer‐blind  RCT . Within‐trial analysis used bivariate regression of costs and quality‐adjusted life years ( QALY s), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost‐effectiveness from a health service perspective.    Results  In the base case analysis, when compared with prednisolone, ciclosporin was cost‐effective due to a reduction in costs [net cost: −£1160; 95% confidence interval ( CI ) −2991 to 672] and improvement in QoL (net  QALY s: 0·055; 95%  CI  0·018–0·093). However, this finding appears driven by a minority of patients with large lesions (≥ 20 cm 2 ) (net cost: −£5310; 95%  CI  −9729 to −891; net  QALY s: 0·077; 95%  CI  0·004–0·151). The incremental cost‐effectiveness of ciclosporin for the majority of patients with smaller lesions was £23 374/ QALY , although the estimate is imprecise: the probability of being cost‐effective at a willingness‐to‐pay of £20 000/ QALY  was 43%.    Conclusions  Consistent with the clinical findings of the  STOP GAP  trial, patients with small lesions should receive treatment guided by the side‐effect profiles of the drugs and patient preference – neither strategy is clearly a preferred use of National Health Service resources. However, ciclosporin‐initiated treatment may be more cost‐effective for patients with large lesions.

Ciclosporin compared with prednisolone therapy for patients with pyoderma gangrenosum: cost‐effectiveness analysis of the STOP GAP trial