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Abstract
Background
The efficacy and safety of biologic and phototherapy in treating moderate-to-severe psoriasis is well known. However, some patients may not respond well to biologic agents or phototherapy on their own and may require combination therapy. Skillfully combining a biologic agent and phototherapy may provide an additive improvement without much increase in risks.
Objective
To summarize the current state of evidence for the efficacy and safety of combining biologics with phototherapy in the treatment of moderate-to-severe plaque psoriasis.
Methods
We conducted an extensive search on Pubmed database for English language literature that evaluated the use of a combination of biologic and phototherapy for the treatment of moderate-to-severe psoriasis through January 2016. The search included the following key-words: psoriasis, etanercept, adalimumab, infliximab, ustekinumab, biologics, phototherapy, and combination therapy.
Results
The primary literature included randomized controlled trials, a head-to-head study, open-label controlled and uncontrolled trials, case series, and case reports. Etanercept was used in over half of the reported cases, but other biologic agents used included ustekinumab, adalimumab, and infliximab. The vast majority of phototherapy was narrowband ultraviolet B (NBUVB) radiation. Most cases reported enhanced improvement with combination therapy. Serious adverse events throughout the study duration were reported in <3% of the patients. Long-term adverse events cannot be excluded.
Conclusion
Combination of biologic and phototherapy appears to be a viable clinical strategy in the treatment of moderate-to-severe psoriasis not responsive to monotherapy, despite limitations in the data available. NBUVB in combination with biologics appears to be especially effective. However, the long-term impact of these combinations is yet to be determined.
Acknowledgments
Dr John Koo is a speaker for AbbVie, Leo, and Celgene. Dr Koo conducts research for Amgen, Janssen, Novartis, Photomedex, Galderma, Pfizer, and Merck. Dr Bhutani is an advisor for Cutanea. Dr Bhutani conducts research for Abbvie, Janssen, and Merck. Drs Koo and Bhutani have no stocks, employment, or board memberships with any pharmaceutical company. The other authors (Mr Benjamin Farahnik, Mr Kourosh Beroukhim, Dr Mio Nakamura, Mr Michael Abrouk, Mr Henry Zhu, Ms Rasnik Singh, and Ms Kristina Lee) report no conflicts of interest.
Disclosure
John Koo is a clinical researcher for Pfizer, Amgen, Janssen and Merck, he is also a speaker for Leo Pharma, Abbvie and Celgene. Dr Bhutani conducts research for Abbvie, Janssen, and Merck. All other authors have no conflicts of interest to disclose.