Register / Log In

Topical combination therapies for psoriasis offer high degree of efficacy, safety




David Pariser, M.D.
Norfolk, Va. — Topical combination treatments for psoriasis offer a high degree of clinical efficacy, patient safety and flexibility in designing treatment regimens, says David M. Pariser, M.D.

"Combination therapy in psoriasis is absolutely the standard of care," says Dr. Pariser, professor of dermatology, Eastern Virginia Medical School, and a Norfolk, Va., dermatologist in private practice. "Virtually all patients with psoriasis are treated with combination therapy. If they're on systemic agents, there will often be a few spots that don't respond as well. Therefore, topical therapies are important for virtually everyone who has psoriasis," no matter how mild or serious their disease.

"Topical corticosteroids in one form or another, usually the more potent ones, are the most commonly prescribed topical agent for psoriasis," he says. In addition, "There's a lot of interesting data on combination therapy using vitamin D topically, along with topical steroids."

Meta-analysis

A recent meta-analysis of 50 randomized, controlled trials analyzed combination psoriasis treatments in comparison to monotherapies. When researchers stratified results by corticosteroid class, Dr. Pariser says, "They concluded that by adding a corticosteroid to a calcipotriene regimen, the likelihood of disease clearance increased by 28 percent for a Class 1 corticosteroid (95 percent confidence interval/CI: 16 to 41 percent) and 14 percent for a Class 2 steroid (95 percent CI: 5 to 22 percent; Bailey EE, Ference EH, Alikhan A, et al. Arch Dermatol. 2011 Dec 19. [Epub ahead of print])." Compared to vitamin D derivative monotherapy, combining vitamin D with corticosteroids conferred a 22 percent higher likelihood of clearance, he says.

"That's a significant finding that supports the notion that we've all had clinically over many years that adding the corticosteroid to the vitamin D does make it work better, and over time can actually achieve clearance" in the percentages specified above, Dr. Pariser says.

In two studies that contained sufficient data to analyze efficacy in terms of reductions in disease severity scores, investigators found that combination therapy with any corticosteroid class decreased disease severity by 1.52 units of standard deviation (95 percent CI: -2.56 to -0.48) versus vitamin D derivative monotherapy.

Conversely, in the same meta-analysis, if patients used a Class 3 or weaker steroid in combination with topical vitamin D, it did not improve disease clearance compared with vitamin D derivative monotherapy, says Mark Lebwohl, M.D.

Product update

Combination products available in the United States include a fixed combination of betamethasone dipropionate and calcipotriene, Dr. Pariser says. In a four-week study, the combination product worked better than either of its ingredients used separately, or its vehicle (Kaufmann R, Bibby AJ, Bissonnette R, et al. Dermatology. 2002;205(4):389-393).

In this study, investigators randomized 1,603 patients to one of four double-blinded treatments: once-daily combination ointment, betamethasone dipropionate ointment, calcipotriol (known as calcipotriene in the United States) ointment, or the ointment vehicle.

When treatment ended, mean percentage improvements in Psoriasis Area and Severity Index (PASI) scores were 71.3 percent, 57.2 percent, 46.1 percent and 22.7 percent, respectively. Additionally, investigators concluded that the combination treatment was well tolerated: 6 percent of patients who used it experienced local adverse reactions, versus 4.9 percent of betamethasone dipropionate users, 11.4 percent of calcipotriol users and 13.6 percent of vehicle users.

Patients also can accomplish combination regimens by purchasing topical steroid and topical vitamin D products separately, or having the combination compounded a compounding pharmacy, Dr. Pariser says.


In coming years, the trend toward less invasive technologies will continue not only in fat removal and body sculpting treatments, but also in new modalities for delivering a variety of drugs, according to physicians who spoke at MauiDerm 2012: Advances in Cosmetic and Medical Dermatology in February.

Above and beyond its therapeutic value in cosmetic medicine, botulinum toxin can be useful in a number of medical indications and can represent an adjunct treatment option, said Philippe Humbert, M.D., Ph.D., at the 20th annual European Academy of Dermatology and Venereology Congress last October.

Several newly approved therapies have changed and are continuing to change the treatment of melanoma therapy so that it is no longer the "black sheep" of cancer therapy, according to Adil Daud, M.D.

Physicians with the most satisfied patients aren't necessarily the ones who spend the most time with patients. Sometimes, even getting the highest-quality goods or services doesn't make up for a poor interaction.

Dr. Laser, in an attempt to lower office fees, taught his nurses to use lasers for various problems such as hair removal, facial toning and acne treatment. He sent his staff to many training courses and established rigid in-office guidelines for laser treatments. Unfortunately, a patient treated by a laser nurse now has a scar on her upper lip, and she filed a complaint against the nurse and Dr. Laser with the state board of nursing.