Combination, rotational, and sequential therapies

In patients with moderate-to-severe psoriasis remission can be difficult to achieve and sustain thus both short-and long-term maintenance agents are needed. The benefits of combination, rotational, and sequential therapies rely on the use of lower-dose therapeutic agents to minimize toxicity. In the case of combination therapy, additive or synergistic effects may result in enhanced efficacy; however, the dangers of additive toxicity or immunosuppression must be considered. Apparent synergistic enhancement is seen with most paired combinations of the four major conventional therapies for severe psoriasis: acitretin, phototherapy, cyclosporine, and methotrexate (MTX). Over the last few years, our greater understanding of the immune system’s involvement in the etiology of psoriasis has led to a number of treatments that target specific steps in the immunopathogenesis of the disease. Thus, combination therapies using the systemic agent mycophenolate mofetil and the newer biologic agents (i.e., infliximab, etanercept, adalimumab, alefacept, and efalizumab) have recently been reported. Using two or more therapies is often necessary for most patients with moderate-to-severe psoriasis, but picking a combination that serves to balance safety and efficacy needs careful consideration. Topical, systemic, and ultraviolet therapies may be used in combination, rotational, or sequential therapy in patients with moderate-to-severe psoriasis. This chapter will emphasize the use of multiple therapeutic agents in combination therapy, but will also review rotational and sequential therapeutic options.