Safety considerations with combination therapies for psoriasis

ABSTRACT

Introduction: Psoriasis is a chronic inflammatory skin disease that waxes and wanes, and long-term remission can be difficult to achieve regardless of disease severity. Currently, numerous treatment options are available for psoriasis including steroid and non-steroid topical agents, phototherapy, oral systemic agents, and biologics, with many more therapeutic agents under development.

Areas covered: This article will review various combination therapy strategies such as rotational therapy and sequential therapy and describe a variety of safe and effective combination therapies for the treatment of psoriasis. Two or more agents with different mechanisms of action and safety profiles can be used to achieve and/or maintain adequate disease control while minimizing the toxicity of treatments. Combination therapy can also be used when a single agent is not enough for treating recalcitrant disease. Choosing a combination regimen that maximizes safety and efficacy while considering patient usability and compliance can be a challenge.

Expert opinion: Given the various treatment options currently available for psoriasis and more agents under development, combination therapy will continue to be a valuable treatment strategy for any patient with psoriasis. It is crucial for clinicians to carefully consider the fine balance between safety and efficacy when combining various therapeutic agents.

KEYWORDS:

• Psoriasis
• safety
• combination therapy
• rotational therapy
• sequential therapy
• phototherapy
• systemic therapy
• biologics

Article highlights

• Psoriasis is a chronic inflammatory skin disease requiring management of both acute flares and long-term maintenance of disease control. Numerous treatment options are available for psoriasis including steroid and non-steroid topical agents, phototherapy, oral systemic agents, and biologics with opportunities to combine various therapies.

• Combination therapy involves the use of two or more agents with different mechanisms of action and safety profiles to achieve and maintain adequate disease control while minimizing toxicity of treatments.

• While rotational therapy involves rotating available psoriasis treatments every 2 to 3 years to minimize cumulative toxicity by allowing for long period of time off each treatment, sequential therapy involves the use of an efficacious, rapid-acting but more toxic agent to treat acute flares, followed by a transition to a less efficacious and slower-acting, yet safer treatment for long-term disease control.

• There is convincing evidence of the efficacy and safety of many combination therapies including topical steroids with topical vitamin D or A agents, phototherapy with topical vitamin D or A agents, and phototherapy with acitretin.

• Convincing evidence for the use of other combination therapies, especially the long-term use of certain systemic and biologic agents in combination, are lacking and further research is needed.

This box summarizes key points contained in the article.

Declaration of interest

J Koo is an advisor/consultant/speaker for AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen, LEO, Merck/Sun, Novartis, Regeneron, Sanofi, and Valeant. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they have been a consultant to AbbVie, Amgen, Bausch Medical, Celgene, Janssen, Leo Pharma, Lilly, Novartis, Sanofi-Genzyme and Sun Pharma. All other peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.