Psoriasis Treatment Combination Therapy

Phototherapy + Drugs/Tar/Anthralin

1. Acitretin

It has been widely accepted that combining acitretin with photo therapy either UVB or PUVA is beneficial. PUVA is being used less because of the risk of skin cancers. This has meant that UVB is the most convenient and most commonly used in combination with retinoids for moderate to severe psoriasis which is unresponsive to topical therapy. A low dose of acitretin in the range of 10 to 25 mg daily is started about two weeks before adding UVB. This combination is one of the safest treatments available for moderate to severe psoriasis with no long-term adverse effects documented. Short-term effects of dry skin, thinning of hair and photosensitivity apparently are reduced by lowering the dose of both the retinoid and UVB. The dose of UVB is reduced to avoid photo toxicity.

Acitretin when combined with narrow band UVB (311 nanometers) has been shown to be more effective than broad band UVB. Some believe this combination is as effective as PUVA. It is certainly simpler and safer. The long term remission rate may not be as high as PUVA. Click here to view the A-Detail™ on Acitretin (Soriatane©).

Methotrexate, Cyclosporine, and UVB

This combination is synergistic allowing a reduction in the total dose of both methotrexate and UVB. There is frequently a rebound on stopping both of these modalities. Cyclosporine can be used in combination with UVB but has not been studied extensively. There is a concern about increasing the risk of squamous cell carcinoma because of the immunosuppressive effect of cyclosporine combined with ultraviolet light.

Topical Calcipotriol / Tazarotene

Studies suggest that UVB and Dovonex produces a much greater response than UVB and placebo ointment. UVB twice a week combined with Dovonex was as effective as UVB administered three times a week. The Dovonex should be applied more than two hours before UVB exposure. Tazarotene can be combined with UVB which is particularly useful for resistant lesions. The patients burn more easily because of the thinning effect on the epidermis produced by the tazarotene. UVB doses are usually reduced by up to one third when tazarotene is used in combination.

Tar and Anthralin

The Goeckerman regime is still one of the most effective treatments for clearing psoriasis. This is combining tar with UVB. The Ingram regime uses anthralin and UVB. Short contact tar and anthralin when combined with UVB can produce remission in about 70 percent of patients which can be maintained for about six months.

Dovobet®

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INTRODUCTION
Dovobet (50 micrograms/gram calcipotriol and 0.5 milligrams/gram betamethasone dipropionate) is a topical ointment approved for use in Canada to treat plaque psoriasis. Dovobet has become the topical therapy of choice for many patients with plaque type psoriasis not involving the face or skin folds... | Read more ...

CLININCAL EXPERIENCE
More than six international studies involving over 6,000 patients have shown reductions in the PASI (Psoriasis Area and Severity Index) of approximately 40% after one week of treatment and 70% after four weeks... | Read more ...

INDICATIONS
Used to treat chronic plaque psoriasis that covers less than 30% of the body surface (see following slides for clarification). Dovobet is not often used to treat the scalp because the sticky base does not allow for easy application or removal... | Read more ...

PATIENT PROFILE
Patients with chronic plaque psoriasis that covers less than 30% of the body surface. In some cases, a patient could use it on a greater BSA if he/she wanted to as long as the use/week is 100 g per week or less... | Read more ...

DOSING
Dovobet should be applied to the affected area once daily for four weeks. Several studies have shown that there are no statistically significant differences between applying the ointment once daily or twice daily... | Read more ...

EFFICACY
Six international studies involving more than 6,000 patients using Dovobet to treat psoriasis have shown PASI reductions of approximately 40% after one week of treatment and 70% after four weeks. Additional studies have shown that Dovobet has superior... | Read more ...

COMPLIANCE
Compliance is aided by the convenience of the once daily dosing of Dovobet. Compliance is also less of a problem than with most products due to the rapid onset of action. Significant improvement is usually seen within the first week... | Read more ...

SIDE EFFECTS, SAFETY AND RISKS
Because Dovobet is a combination drug, the frequency of side effects reported is less than would be expected if using each compound on its own: for example, the anti-inflammatory action of the corticosteroid (betamethasone dipropionate) minimizes the irritation often reported when using calcipotriol alone... | Read more ...

COST OF TREATMENT
It is probably the single most effective topical therapy available for psoriasis, so patients are generally prepared to pay for this. It is somewhat more expensive than the equivalent potent topical steroid, but the rapid and significant improvement in quality of life... | Read more ...

View the entire Dovobet^® presentation.