Biologic Therapy With or Without Topical Treatment in Psoriasis: What Does the Current Evidence Say?

J. Daniel Jensen; Macey Renault Delcambre; Gloria Nguyen; Naveed Sami

Disclosures

Am J Clin Dermatol. 2014;15(5):379-385. 

In This Article

Abstract and Introduction

Abstract

Biologic therapy represents a relatively new class of drugs which have revolutionized the treatment of psoriasis and are used with increasing frequency in order to control this chronic, systemic inflammatory disease. However, it is unclear what role there is for combination therapy of biologics with traditional topical agents. The purpose of this article is to assess the literature on the role of topical agents as adjuvants to biological treatments in the treatment of psoriasis and identify areas for further research. A MEDLINE search was performed in order to identify English-language publications from 1996 to 2014 examining combination biologic therapy with topical medications in the treatment of psoriasis. Data from these clinical studies are summarized and the outcomes are discussed. In general, the addition of adjuvant topical therapy to systemic biologic therapy allowed for a reduction in dosage and side effects of both agents, maintenance of initial response to biologics, treatment of recalcitrant lesions in partial responders, and potential acceleration of response to biologic therapies. The current data, though limited, suggest that using topical therapies as adjunct treatment to biologics is a well tolerated and effective means of controlling psoriasis and improving quality of life for patients. However, the treating physician should remain attentive to signs of adverse events and seek opportunities to reduce the dose or treatment frequency during chronic use.

Introduction

Psoriasis is a chronic inflammatory disease that is estimated to affect approximately 1–3 % of the world's population, depending on geographic region.[1] Nearly one quarter of those affected have moderate to severe disease affecting more than 3 % of body surface area (BSA) or affecting critical areas such as hands, feet, face, or genitalia.[1,2] Topical therapies have served as the conventional mainstay for the treatment of mild psoriasis for many years. Although generally effective, topical treatments may not be practical or efficacious as monotherapy for those with moderate to severe disease, and especially for patients who also have associated psoriatic arthritis.[2] Therefore, systemic medications are often required for adequate treatment of moderate to severe disease. This treatment paradigm is reflected in the literature put forth by several international consensus panels, which have developed well defined algorithms for the treatment of psoriasis.[3–5] Systemic therapy for psoriasis has, until recent years, been dominated by systemic agents such as methotrexate, cyclosporine, and retinoids. While these agents present patients with a new set of side effects and potential risks, they have generally been an effective and integral part of psoriasis treatment for several decades. The advent of systemic biologic agents which target inflammatory cytokines involved in psoriasis pathogenesis, however, has revolutionized the treatment of moderate to severe psoriasis over the past decade. These drugs, many of which are indicated for both psoriasis and psoriatic arthritis, have provided clinicians and patients with a much needed alternative to traditional systemic therapies. However, despite their superior efficacy, rapid and complete clearance is not always obtained with treatment with biologic therapies. This phenomenon may either be related to (i) the a priori inability of a particular biologic to clear psoriasis, or (ii) possible secondary formation of anti-drug antibodies (ADAs) which neutralize the effect of the biologic, causing psoriasis relapse. Since it is often difficult to distinguish between these two possibilities and testing for ADAs is often unavailable, many clinicians are left trying to augment the results of the biologics with adjuvant topical therapies.[6]

Herein, we present the current clinical data on adjuvant topical treatments in the setting of biologic therapy for psoriasis. Additionally, we suggest general guidelines for the identification of good candidates for combination therapy, advise on selection of appropriate topical therapies, and identify gaps in the literature that merit further investigation.

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