Authors: Maria Elinor Grace Q. Sison, MD, Francesca Mari P. Sumilang, MD and Ma. Lorna F. Frez, MD, FPDS

Abstract

Background: Combination therapy for moderate to severe chronic plaque psoriasis may be indicated for patients resistant to monotherapy with first line agents such as topical therapy.

Objectives: This review was conducted to assess the efficacy and safety of combination therapies versus monotherapy as treatment for moderate to severe psoriasis.

Methods: Electronic search of of MEDLINE, Cochrane Skin Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and HERDIN, from 1991 to 2015 was conducted. Search terms used were: “combination treatment” OR “combination therapy” AND “moderate to severe psoriasis”. We also searched trials databases, hand searched journals, cross-references, scanned reference lists and contacted authors. Randomized controlled studies with head-to-head comparisons of combination therapy with monotherapy for moderate to severe chronic plaque psoriasis were included. Primary outcomes were improvement or clearance of psoriasis as measured by Psoriasis Activity and Severity Index (PASI) scores, PASI 75, PASI 90, achievement of Physician Global Assessment of clear or almost clear, and change in Dermatology Life Quality Index scores. Secondary outcomes were reported adverse events. Treatment effect measured was mean difference between scores of combination therapy and monotherapy?

Results: Six randomized controlled trials which compared etanercept + methotrexate, PUVA + isotretinoin, acitretin + etanercept, clobetasol propionate + etanercept, NBUVB + alefacept, and cyclosporine A + calcipotriol/betamethasone dipropionate ointment favored combination therapy over monotherapy for mean change in PASI with I2 of 75% for a total of 1,308 participants in 6 studies. The combination of narrowband UVB to other therapies comprised majority of the studies (8 out of 17). Etanercept combined with other therapies (3 studies) also showed significant results in achieving PASI 75. These studies are the following: Gottlieb 2012 (ETN + methotrexate, PASI 75 77.3% at week 24 (No mean, SD and CI mentioned), p value <0.001), Lebwohl 2013 (ETN + clobetasol propionate, PASI 75 65.2% at week 12 (No mean, SD and CI mentioned), p value <0.001), Gisondi 2008 (ETN + acitretin, PASI 75 45% (no CI mentioned) at week 24, p value 0.001). The adverse events were mild to moderate, and the incidence of serious adverse events was low and comparable in the treatment groups.

Conclusion: Combination therapy using etanercept + methotrexate, PUVA + isotretinoin, acitretin + etanercept, clobetasol propionate + etanercept, NBUVB + alefacept, and cyclosporine A + calcipotriol/betamethasone dipropionate ointment can be explored in treating patients with moderate to severe psoriasis who are frustrated with their current therapies because they were found to be more effective than monotherapy. Treatment should still be individualized for each patient.

Citation

Sison, ME, Sumilang, FM & Frez, ML. (2017). Combination therapy versus monotherapy for moderate to severe chronic plaque psoriasis in adults. Journal of the Philippine Dermatological Society, 26(1), 36-45.

Keywords

combination treatment, combination therapy, moderate to severe psoriasis

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