Combination Treatment for Severe Psoriasis

If you have moderate to severe psoriasis and you haven’t been able to clear your skin as well as you’d like, it may be time double up. Combination therapy -- using two different psoriasis treatments at the same time -- can work very well for severe conditions.

Your doctor would count your psoriasis as severe if it covers more than 10% of your body. But it also matters how much the disease affects your quality of life. If your symptoms hold you back from socializing or doing everyday activities, your case could be severe.

Treatment Choices

Many psoriasis medications and therapies can be used alone or together.

Topical medications. These are creams and ointments you put on your skin. The most common ones are corticosteroids. Others include vitamin D compounds, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, and coal tar.

Phototherapy. It’s also called ultraviolet radiation treatment. It uses several form of light, including sunlight, ultraviolet B (UVB), and photochemotherapy (PUVA), which uses deeper-piercing ultraviolet A rays.

Whole body medications. You take these drugs by mouth, with a shot, or through an IV. These powerful drugs are called systemic because they work throughout your body, not just on your skin. They include methotrexate, cyclosporine, and retinoid capsules. Another option is biologics, which are drugs made from living cells and which target specific proteins that can set off psoriasis.

Advantages of Combining

Using two treatments at once can have several benefits.

Fewer side effects: Many psoriasis medications can cause problems like diarrhea, headaches, or higher chances of infections. Combining two therapies can let you take each in lower doses, lessening the side effects and possible harms. For example, less intense phototherapy may lower your chances for skin cancer.

Customized treatment: Pairing different drugs gives your doctor more flexibility and choices to design your treatment plan. Combination therapy also may work quicker and better than one treatment alone. Also, some drugs can boost another drug’s power. Salicylic acid, for instance, helps corticosteroids better seep into your skin.

Longer relief: Teaming two treatments may let you stick with it for longer. It also may keep your disease in remission for longer stretches after you quit treatment.

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Drawbacks

A possible downside to paring treatments is that you have to follow two different guidelines and schedules. Not all drugs are useful or even safe to combine. It also may cost more than a single treatment or require more medical visits.

On the flip side, you’re more likely to follow your doctor’s orders if combination treatment better controls your symptoms.

Is It Right for You?

Combination therapy isn’t for everyone, and two people can respond differently to the same treatment. But you might be a good candidate if you:

  • Tried and failed with single therapy
  • Can’t tolerate certain treatments at full dose
  • Have complications or conditions stemming from your psoriasis
  • Need long-term treatment for psoriasis that comes back
  • Need a therapy that can be tailored to a specific medical or health problem

 

Powerful Couples

Not all psoriasis treatments are useful or even safe to combine. You shouldn’t use salicylic acid on your skin in combination with UVB phototherapy, because it makes the UVB less effective. Also, cyclosporine in combination with psoralen plus ultraviolet A can make you more likely to get cancer.

These combinations have track record of working well:

Topicals + topicals

  • Corticosteroids and salicylic acid
  • Corticosteroids and vitamin D compounds
  • Corticosteroids and tazarotene cream

Phototherapy + topical therapies    

  • UVB plus topical calcipotriene (Dovonex).
  • UVB plus anthralin and topical coal tar products (Ingram regimen)

Phototherapy + phototherapy

  • UVB plus PUVA

Phototherapy + systemics                

  • UVB plus methotrexate
  • PUVA plus retinoids

Systemics + topical medication

  • Acitretin plus topical calcipotriene
  • Cyclosporine plus topical calcipotriene

Phototherapy + biologics

  • Narrow-band UVB plus biologics                     

If your current treatment doesn’t give you enough relief, talk to your doctor about trying a new approach.

WebMD Medical Reference Reviewed by Debra Jaliman, MD on December 03, 2018

Sources

SOURCES:

National Psoriasis Foundation: “About Psoriasis.”

Mayo Clinic: “Psoriasis.”

American Academy of Dermatology: “Medications and light treatments for psoriasis,” “Psoriasis: Combinations of topical therapies,” “Psoriasis: Recommendations for UVB combination therapies.”

Journal of the American Academy of Dermatology: “Combination therapy to treat moderate to severe psoriasis.”

American Journal of Clinical Dermatology: “Use of Biologic Agents in Combination with Other Therapies for the Treatment of Psoriasis,” “Combination therapy in psoriasis: an evidence-based review.”

American Family Physician: “Treatment of Psoriasis: An Algorithm-Based Approach for Primary Care Physicians.”

Psoriasis: “Combining biologic and phototherapy treatments for psoriasis: safety, efficacy, and patient acceptability.”

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