Joint Phototherapy Guidelines Week 3: Combination Therapy with Narrow Band UVB

Last month, the American Academy of Dermatology and the National Psoriasis Foundation released guidelines of care for the management and treatment of psoriasis with phototherapy. Over the next few weeks, we’ll examine the recommendations and share information about the significance for your practice and patients.

Week 1: Treating with Narrow Band UVB

Week 2: Home Narrow Band UVB

Week 3: Combination Therapy with Narrow Band UVB

Week 4: Risks of Narrow Band UVB

Week 5: Broadband UVB Overview, Risks & Recommendations

Week 6: PUVA Overview, Risks & Recommendations

Week 7: Summary

Combination Therapy with Narrow Band UVB:

Information included in this blog post has come from the joint guidelines developed by the American Academy of Dermatology and the National Psoriasis Foundation. Daavlin does not dispense medical advice. For detailed insight regarding the use of combination therapies, review the AAD and NPF joint phototherapy guidelines in full.

In order to enhance efficacy, additional medications are sometimes used in combination with phototherapy. Patients with moderate to severe psoriasis, with stubborn conditions and those who don’t respond to monotherapy as quickly as desired are potential candidates for combination therapy.

The chart below provides an overview of the joint findings and recommendations:

TherapyRecommended to use as combination therapy with NB-UVB?Comments
CalcipotriolUndeterminedThe data are mixed.  In one study, Calcipotriol did not improve efficacy. In another study, fewer treatments of NB-UVB were needed to reach clearance.
TazaroteneUndeterminedThe data are also mixed.  In one study, tazarotene decreased responsiveness to phototherapy.  In a more recent study, improvement was shown in patients with plaque psoriasis.
Topical PsoralensInsufficient evidence to recommendThe group in the cited study using psoralen and NB-UVB required fewer treatments and a lower cumulative dose, however; patients experienced more adverse side effects.
MethotrexateYesPatients required fewer weeks of treatment to obtain clearance, fewer UVB exposures, lower cumulative dose of UVB and lower cumulative dose of methotrexate.
Oral RetinoidsYesFewer UVB treatments and less accumulative dose of light therapy was required.  These may be especially helpful in treating patients with an increased risk of skin cancer.
CyclosporineNoThere is a lack of significant supporting evidence and potential for “increased risk of nonmelanoma skin cancer secondary to immunosuppression and UV exposure.”
Fumaric Acid EstersYesPhototherapy is especially useful at the beginning of FAE therapy in the treatment of psoriasis.
EtanerceptYesCombination treatment is recommended for those cases in which monotherapy for either treatment type is ineffective.
AdalimumabUndeterminedWhile patients in the combination therapy study showed improvement, there were no monotherapy arms of the study for comparison.
UstekinumabYesPatients in the study were all treated with ustekinumab and half of their body was treated with NB-UVB light.  Results demonstrated better PASI scores for areas of the body exposed to NB-UVB light.
ApremilastYesThis “combination circumvents the need for regular injections” and is effective in treating psoriasis.
PUVAInsufficient evidence to recommendIncreased efficacy, fewer treatments and lower cumulative doses than using one type of light alone; however, concerns remain about the long-term risk of photocarcinogenesis with this combined therapy.

Next week’s blog post will address the risks of treating with Narrow Band UVB.  Looking for more information now?  Visit our website to read a safety comparison between phototherapy and biologics.