Combining biologic and phototherapy treatments for psoriasis: safety, efficacy, and patient acceptability

Figures & data

Table 1 Combinations of biologics with NBUVB for treatment of psoriasis

Author	Year	Nonbiologic treatment	Design	Study population	Age (years)	Prior systemic treatment	Patients (n)	Treatment	Endpoint	Efficacy	Safety of combination	Comment
Kircik et al^Citation10	2008	NBUVB/ETN	Open-label, uncontrolled, single arm	Moderate-to-severe plaque psoriasis	Mean, 40.6	Oral: MTX (13), systemic steroids (13), ACT (12), CSA (4), tacrolimus (1) Biologic: alefacept (4) Other systemic: (9)	86	ETN 50 mg BIW + NBUVB (three sessions/week)	PASI-75 at week 12	At week 12, 84.9% achieved PASI-75, 26% achieved PASI-100	No SAEs reported	–
De Simone et al^Citation9	2011	NBUVB/ETN	Open-label, uncontrolled, single-arm	Moderate-to-severe plaque psoriasis	Mean, 48.3	NR	33	ETN 50 mg QW + NBUVB (three sessions/week) for 8 weeks, then ETN monotherapy for 4 weeks	PASI-75 at week 12	At week 12, 81.8% achieved PASI-75; 57.6% achieved PASI-90; and 24.2% achieved PASI-100.	No SAEs reported	–
Wolf et al^Citation11	2009	NBUVB/ETN	Open-label, controlled, half-body comparison study	Moderate-to-severe plaque psoriasis, not achieving PASI-75 after 6 weeks of ETN 50 mg BIW	Mean, 57 range, 48–66	Light therapy: NBUVB (5)	5	ETN 50 mg BIW weeks 1–12 + half-body NBUVB, 3 sessions/week (weeks 6–12)	Half-body mean PASI score at week 12	At week 12, mean PASI reduction from baseline was 89% (ETN + UVB) vs 68% (ETN; P<0.001)	No SAEs reported	–
Calzavara-Pinton et al^Citation14	2013	NBUVB/ETN	Randomized controlled intraindividual comparison study	Moderate-to-severe plaque psoriasis not achieving PASI-75 after NBUVB as first-line therapy and etanercept as second-line therapy	Mean, 40.4 range, 18–84	Biologic: etanercept alone Light therapy: NBUVB	8	ETN 50 mg BIW for 12 weeks, if patients did not achieve PASI-75 and were ineligible for conventional systemic therapy, NBUVB (3 sessions/week) was added (mean 14.6 ± 3.3 NBUVB sessions) (n=8)	PASI-75 at week 24	At 24 weeks, 8/8 (100%) achieved PASI-75	No SAEs reported	PASI-75 was achieved in 262 patients (81.4%) treated with NBUVB monotherapy.
Park et al^Citation18	2012	NBUVB/ETN	Pilot, randomized, “head-to-head” prospective comparison study	Psoriasis patients with a BMI > than 30 (average BMI 38.6)	Mean, 44 years range, 18–80	NR	13	1. ETN 50 mg BIW for 12 weeks, then ETN 50 mg QW for 12 weeks 2. ETN 50 mg BIW for 12 weeks, then ETN 50 mg QW + NBUVB (3 sessions/week) for 12 weeks (n=13)	PASI-75 at week 24	At week 24, 46.7% of subjects in the ETN monotherapy group, versus 53.3% in the ETN+ NBUVB group achieved PASI-75	No SAEs reported	Limited by relatively small sample size, unable establish significance. A total of five patients did not complete the study.
Lynde et al^Citation12	2012	NBUVB/ETN	Randomized, open-label single-blinded study	Psoriatic patients not achieving PASI-90 after 12 weeks of ETN treatment	Mean, 43.9 range, 18–77	Biologic: etanercept alone	75	ETN 50 mg QW monotherapy or in combination with NBUVB (3 sessions/week) for a period of 4 weeks (n=75)	PASI-90 at 24 weeks	At week 24, 16.2% of patients in the combination group and 15.8% of patients in the ETN monotherapy group achieved PASI-90. In those with high adherence to NBUVB, the PASI-90 at week 16 was 42.9% for etanercept with NBUVB, compared with 3.4% for etanercept monotherapy (P=0.018).	No SAEs reported	The combination of NBUVB/ETN enhanced the PASI response at weeks 16 and 24 in a small subset of patients with a high adherence to the NBUVB treatment.
Gambichler et al^Citation13	2011	NBUVB/ETN	Prospective, investigator-blinded, within-patient irradiated/nonirradiated, controlled study	Moderate-to-severe psoriasis	Mean, 42	NR	14	ETN 25 mg BIW + NBUVB, 3 sessions/week for 6 weeks. One marker lesion covered as nonirradiated control for 6 weeks	M-PASI	After 6 weeks, the relative M-PASI reduction (mean ± SD) in ETN only sites (53.7±36.9%) was significantly lower than the reduction in ETN+ NBUVB-treated lesions (64±27.8%; P=0.011)	No SAEs reported	–
Wolf et al^Citation15	2011	NBUVB/ADA	Open-label, controlled, half-body comparison study	Moderate-to-severe plaque type psoriasis	Mean, 59 range, 49–67	Oral: MTX (2), ACT (2), fumaric acid (1), PUVA (2) Biologic: ETN (3), ADA (1), alefacept (1) Light therapy: UVB broadband (1), NBUVB (1)	4	ADA 80 mg, week 0; 40 mg BIW + NBUVB to randomly selected body half (left or right, excluding the head), 3 sessions/week for 6 weeks	Half-body PASI at 6 weeks	Mean PASI reduction from baseline (start of ADA) of 86% on UV-irradiated body halves vs 53% on nonirradiated body halves	No SAEs reported	–
Bagel^Citation16	2011	NBUVB/ADA	Single-center, single-arm, open-label, prospective pilot study	Moderate-to-severe plaque type psoriasis	Mean, 39 range, 19–62	No prior therapy	20	ADA 80 mg, week 0; 40 mg week 1; 40 mg every other week + NBUVB, 3 sessions/week	PASI-75 at week 12	At week 12, 95% achieved PASI-75, 75% achieved PASI-90, 55% achieved PASI-100	No SAEs reported	Limited by relatively small sample size, and an uncontrolled and unpowered single arm
Wolf et al^Citation17	2012	NBUVB/ustekinumab	Randomized, half-body comparison study	Moderate-to-severe plaque psoriasis	Mean, 58 range, 48–66	Oral: MTX (5), ACT (5), fumaric acid (6), Biologic: alefacept (1) efalizumab (2) ETN (8) ADA (3) infliximab (2) Light therapy: UVB broadband and/or NBUVB therapy (8), PUVA (10)	10	Ustekinumab (standard dosage) at weeks 0 and 4 + NBUVB randomly selected body half (left or right, excluding the head), 3 sessions/week for 6 weeks. (n=9)	Half-body PASI at 6 weeks	At week 6, 7/9 patients (78%) in the UV-irradiated body half arm and 1/9 patients (11%) in the nonirradiated body half arm achieved PASI-75 (P=0.007).	1/10 (10.0%) of patients reported SAEs in the UV-irradiated body. Circumscribed herpetic eruption (1), patient was discontinued from study.	–

Note: ‘–’ indicates no data.

Abbreviations: ACT, acitretin or oral retinoid; ADA, adalimumab; BIW, twice weekly; BMI, body mass index; CSA, cyclosporine; ETN, etanercept; MTX, methotrexate; n, number of patients; NBUVB, narrow band ultraviolet B; NR, not reported; PASI, Psoriasis Area Severity Index; PUVA, psoralen + ultraviolet A; QW, every week; SAE, serious adverse event; UV, ultraviolet; UVB, ultraviolet B.

KircikLBagelJKormanNUtilization of narrow-band ultraviolet light B therapy and etanercept for the treatment of psoriasis (UNITE): efficacy, safety, and patient-reported outcomesJ Drugs Dermatol20087324525318380206

 PubMed Web of Science ®Google Scholar

De SimoneCD’AgostinoMCapizziRCapponiAVenierACaldarolaGCombined treatment with etanercept 50 mg once weekly and narrow-band ultraviolet B phototherapy in chronic plaque psoriasisEur J Dermatol201121456857221697032

 PubMed Web of Science ®Google Scholar

WolfPHoferALegatFJTreatment with 311-nm ultraviolet B accelerates and improves the clearance of psoriatic lesions in patients treated with etanerceptBr J Dermatol2009160118618919067710

 PubMed Web of Science ®Google Scholar

Calzavara-PintonPGSalaRArisiMRossiMTVenturiniMOrtelBSynergism between narrowband ultraviolet B phototherapy and etanercept for the treatment of plaque-type psoriasisBr J Dermatol2013169113013623834117

 PubMed Web of Science ®Google Scholar

ParkKKWuJJKooJA randomized, ‘head-to-head’ pilot study comparing the effects of etanercept monotherapy vs. etanercept and narrowband ultraviolet B (NB-UVB) phototherapy in obese psoriasis patientsJ Eur Acad Dermatol Venereol201327789990622702846

 PubMed Web of Science ®Google Scholar

LyndeCWGuptaAKGuentherLPoulinYLevesqueABissonnetteRA randomized study comparing the combination of nbUVB and etanercept to etanercept monotherapy in patients with psoriasis who do not exhibit an excellent response after 12 weeks of etanerceptJ Dermatolog Treat201223426126721797805

 PubMed Web of Science ®Google Scholar

GambichlerTTiggesCScolaNEtanercept plus narrowband ultraviolet B phototherapy of psoriasis is more effective than etanercept monotherapy at 6 weeksBr J Dermatol201116461383138621466532

 PubMed Web of Science ®Google Scholar

WolfPHoferAWegerWPosch-FabianTGruber-WackernagelALegatFJ311 nm ultraviolet B-accelerated response of psoriatic lesions in adalimumab-treated patientsPhotodermatol Photoimmunol Photomed201127418618921729166

 PubMed Web of Science ®Google Scholar

BagelJAdalimumab plus narrowband ultraviolet B light phototherapy for the treatment of moderate to severe psoriasisJ Drugs Dermatol201110436637121455546

 PubMed Web of Science ®Google Scholar

WolfPWegerWLegatFJTreatment with 311-nm ultraviolet B enhanced response of psoriatic lesions in ustekinumab-treated patients: a randomized intraindividual trialBr J Dermatol2012166114715321910714

 PubMed Web of Science ®Google Scholar