0
Evidence-Based Dermatology: Review |

Combination Treatments for Psoriasis:  A Systematic Review and Meta-analysis

Elizabeth E. Bailey, MD, MPH; Elisabeth H. Ference, MD, MPH; Ali Alikhan, MD; Meghan T. Hession, MD; April W. Armstrong, MD, MPH
Arch Dermatol. 2012;148(4):511-522. doi:10.1001/archdermatol.2011.1916.
Text Size: A A A
Published online

Objective To summarize the current state of evidence for combination topical and systemic therapies for mild to severe psoriasis.

Data Sources We performed a systematic search for all entries in PubMed, CINAHL, Cochrane Review, and EMBASE related to combination treatments for psoriasis through July 2010.

Study Selection We included randomized controlled trials that reported proportion of disease clearance or mean change in clinical severity score (or provided these data through communication with study authors) for efficacy of a combination treatment for psoriasis compared with 1 or more corresponding monotherapies.

Data Extraction Study data were extracted by 3 independent investigators, with disagreement resolved by consensus. The proportion of patients who achieved clearance, definition of clearance, means and standard deviations for baseline disease symptom score and final disease symptom score, and major design characteristics were extracted for each study.

Data Synthesis Combination treatments consisting of vitamin D derivative and corticosteroid, vitamin D derivative and UV-B, vitamin A derivative and psoralen–UV-A, vitamin A derivative and corticosteroid, vitamin A derivative and UV-B, corticosteroid and hydrocolloid occlusion dressings, UV-B and alefacept, and vitamins A and D derivatives were more effective than 1 or more monotherapies using the likelihood of clearance as the outcome. Blinding status and potency of the corticosteroid treatment used were significant sources of heterogeneity between studies.

Conclusions The results demonstrate the need for additional long-term trials with standardized outcome measures to evaluate the efficacy and adverse effects of combination therapies for psoriasis and highlight the possible effects of trial design characteristics on results.

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Meta-analysis flowchart. One hundred randomized controlled trials (RCTs) met the inclusion criteria for review and possible inclusion in the meta-analysis. Fifty RCTs were included in the meta-analysis for clearance efficacy, and 10 RCTs were included for disease severity score analysis. *Numbers in italics denote studies that were not included in the analysis because only 1 study with sufficient data was available for the subgroup.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Vitamin D derivative combination therapies and disease clearance efficacy (risk difference [RD]). Combined vitamin D derivative–corticosteroid treatment increased the likelihood of disease clearance compared with vitamin D derivative and corticosteroid monotherapies. Combined vitamin D derivative–UV-B treatment increased the likelihood of disease clearance compared with vitamin D derivative monotherapy but not compared with UV-B monotherapy. Weights are derived from random-effects analysis. Percentages might not total 100 because of rounding. Solid diamonds represent risk estimates for the individual studies; limit lines, 95% CIs; and open diamonds, summary estimates for the group of studies pooled (the pooled estimate).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Vitamin D derivative–corticosteroid combination therapy vs vitamin D derivative monotherapy clearance efficacy by corticosteroid potency class. When stratified by corticosteroid potency class, vitamin D derivative–corticosteroid combination treatment was more effective in inducing disease clearance than vitamin D derivative monotherapy when a class 1 or class 2 corticosteroid was used. It was not more effective when a class 3 corticosteroid was used. Weights are derived from random-effects analysis. Percentages might not total 100 because of rounding. The vertical dashed line indicates the summary estimate when all the studies in the table are pooled for a single estimate. RD indicates risk difference. Other symbols are explained in the legend to Figure 2.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 4. Vitamin A derivative combination therapies and disease clearance efficacy (risk difference [RD]). Vitamin A derivative–psoralen–UV-A (PUVA) combination treatment was more effective in inducing disease clearance than vitamin A derivative or PUVA monotherapies. Vitamin A derivative–corticosteroid combination therapy was more effective than vitamin A derivative monotherapy, and vitamin A derivative–UV-B combination therapy was more effective than UV-B monotherapy. Weights are derived from random-effects analysis. Percentages might not total 100 because of rounding. Symbols are explained in the legend to Figure 2.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 5. Vitamin A derivative–psoralen–UV-A (PUVA) combination therapy vs vitamin A derivative monotherapy clearance efficacy by blinding status. Among unblinded studies, vitamin A derivative–PUVA combination therapy led to a higher likelihood of disease clearance than vitamin A derivative monotherapy. This effect was not statistically significant among double-blinded studies. Weights are derived from random-effects analysis. Percentages might not total 100 because of rounding. The vertical dashed line indicates the summary estimate when all the studies in the table are pooled for a single estimate. RD indicates risk difference. Other symbols are explained in the legend to Figure 2.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 6. Vitamin A derivative–psoralen–UV-A (PUVA) combination therapy vs vitamin A derivative monotherapy clearance efficacy by psoriasis type. When stratified by type of psoriasis, vitamin A derivative–PUVA combination treatment was more effective than vitamin A derivative monotherapy in inducing disease clearance among patients with palmoplantar pustulosis but not for patients with other types of psoriasis. Weights are derived from random-effects analysis. RD indicates risk difference. Symbols are explained in the legend to Figure 2.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 7. Combination UV-B therapies and disease clearance efficacy (risk difference [RD]). Combination UV-B–alefacept therapy was more effective in inducing disease clearance than alefacept monotherapy, and combination UV-B–methotrexate therapy was more effective than UV-B monotherapy. Combination UV-B–balneotherapy, UV-B–psoralen, and UV-B–tar therapies were not more effective than UV-B monotherapy. Weights are derived from random-effects analysis. Percentages might not total 100 because of rounding. Symbols are explained in the legend to Figure 2.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 8. Combination corticosteroid derivative therapies and disease clearance efficacy (risk difference [RD]). Combination corticosteroid–hydrocolloid dressing therapy led to a higher likelihood of disease clearance than corticosteroid monotherapy. Combination corticosteroid–salicylic acid therapy was not more effective than corticosteroid monotherapy, and combination corticosteroid–UV-B therapy was not more effective than UV-B monotherapy. Weights are derived from random-effects analysis. Symbols are explained in the legend to Figure 2.

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
Jobs
brightcove.createExperiences();