Arora Sandeep, Das Pankaj, Arora Gulhima
Department of Dermatology, Army College of Medical Sciences & Base Hospital Delhi Cantt, New Delhi, India.
Consultant Dermatologist, Mehektagul Dermaclinic, New Delhi, India.
Front Med (Lausanne). 2021 Aug 19;8:696597. doi: 10.3389/fmed.2021.696597. eCollection 2021.
Psoriasis continues to have unmet needs in its management despite introduction of newer molecules. Monotherapy with these newer agents may not achieve therapeutic goals in all cases, hence necessitating their combinations with other molecules. Improved understanding of newer as well as conventional treatment modalities and experiences in their combinations hence necessitates therapeutic guidelines for their use in psoriasis. To review the combinations of treatments reported in literature and recommendations for their use based on best current evidence in literature. A literature review of MEDLINE database for studies evaluating combinations of newer therapies with conventional therapies in psoriasis was done. Newer therapies were identified as biologic disease modifying anti rheumatic drugs and other molecules such as apremilast while conventional therapies included methotrexate, cyclosporine, or retinoids, phototherapy and others. The therapeutic guidelines are proposed with the aim to provide evidenced based approach to combine newer and conventional agents in day-to-day psoriasis management. Combination of acitretin and narrow band ultraviolet B (NB-UVB)/Psoralen with ultraviolet A (PUVA) achieves faster clearance and allows reduction of dose of the latter. A variable outcome is reported of methotrexate with TNF-α inhibitors vs. TNF-α inhibitors alone, although addition of methotrexate appears to reduce immunogenicity of TNF-α inhibitors thereby preventing formation of anti-drug antibodies especially in case of infliximab. While combination of acitretin and PUVA is beneficial, combining TNF-α inhibitors and phototherapy too produces better and faster results but long term risks of Non Melanoma Skin Cancers (NMSCs) may preclude their use together. Combination of cyclosporine and phototherapy is not recommended due to greater chances of NMSCs. Adding phototherapy to Fumaric Acid Esters (FAEs) improves efficacy. Apremilast can be safely combined with available biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. Hydroxyurea and acitretin may be used together increasing their efficacy and reducing doses of both and hence their adverse effects. Selected clinical scenarios shall benefit from combinations therapies, improving efficacy of both conventional and newer agents and at the same time helping reduce toxicity of higher dosages when used individually.
尽管有更新的药物问世，但银屑病在治疗方面仍存在未满足的需求。使用这些新型药物进行单一疗法在所有情况下可能无法实现治疗目标，因此需要将它们与其他药物联合使用。对新型以及传统治疗方式的更好理解以及它们联合使用的经验，因此需要制定在银屑病治疗中使用这些药物的治疗指南。为了回顾文献中报道的治疗组合以及基于文献中当前最佳证据的使用建议。对MEDLINE数据库进行了文献综述，以查找评估银屑病中新型疗法与传统疗法联合使用的研究。新型疗法被确定为生物疾病修饰抗风湿药物和其他分子，如阿普斯特，而传统疗法包括甲氨蝶呤、环孢素、维甲酸、光疗等。提出治疗指南的目的是为日常银屑病管理中联合使用新型和传统药物提供循证方法。阿维A与窄谱中波紫外线（NB-UVB）/补骨脂素与长波紫外线（PUVA）联合使用可更快清除皮损，并可降低后者的剂量。甲氨蝶呤与肿瘤坏死因子-α抑制剂联合使用与单独使用肿瘤坏死因子-α抑制剂相比，结果不一，尽管添加甲氨蝶呤似乎可降低肿瘤坏死因子-α抑制剂的免疫原性，从而防止抗药物抗体的形成，尤其是在英夫利昔单抗的情况下。虽然阿维A与PUVA联合使用有益，但肿瘤坏死因子-α抑制剂与光疗联合使用也能产生更好更快的效果，但非黑色素瘤皮肤癌（NMSC）的长期风险可能会妨碍它们一起使用。由于发生NMSC的可能性更大，不建议环孢素与光疗联合使用。在富马酸酯（FAE）中添加光疗可提高疗效。在斑块状银屑病或银屑病关节炎患者中，如果单独使用生物制剂效果不佳，阿普斯特可与现有生物制剂安全联合使用。羟基脲和阿维A可一起使用，提高疗效并降低两者的剂量，从而减少它们的不良反应。某些临床情况将受益于联合治疗，提高传统药物和新型药物的疗效，同时有助于降低单独使用高剂量药物时的毒性。
