Can Psoralen Ultraviolet-A or Narrowband Ultraviolet-B Salvage the Biologic Drug Response After a Secondary Failure? A Retrospective Cohort Study
Introduction: Biologic drug survival in psoriasis is mainly limited by a decrease of effectiveness over time. Strategies to improve retention rates are needed. Our purpose was to evaluate the efficacy and tolerability of concurrent narrowband ultraviolet- B (NB-UVB) or photochemotherapy (PUVA) to salvage the biologic drug in secondary non-response.
Methods: Retrospective cohort study of 18 adults with moderate-to-severe plaque psoriasis treated with biologics who received concurrent phototherapy after a secondary efficacy loss.
Results: Twelve patients underwent PUVA concurrently with etanercept and adalimumab in 13 and 5 cycles, respectively. Clinical response was observed in 72.2% of cycles (PASI75 55.5%). Median PASI decreased by 73%. Sustained response was observed for 25 months (median). A malignant melanoma was identified during follow-up. Six patients underwent NB-UVB concurrently with etanercept, adalimumab and ustekinumab in 7.3 and 2 cycles, respectively. Clinical response was observed in 75% of cycles (PASI75 41.7%). Median PASI decreased by 80%. Sustained responde was observed for 21 months (median).
Conclusions: This study adds real-life evidence that PUVA and NB-UVB are effective options to salvage and improve the long-term performance of biologic drugs. Further efficacy and safety data, especially addressing the skin malignancy risk, should be sought to clarify the role of this interesting approach in the modern era of improved biologic therapies.
Jungo P, Maul JT, Djamei V, von Felten S, Kolios AGA, Czernielewsk J, et al.Superiority in Quality of Life Improvement of Biologics over Conventional Systemic Drugs in a Swiss Real-Life Psoriasis Registry. Dermatology. 2016;232:655-63. doi: 10.1159/000455042.
Menter A, Papp KA, Gooderham M, Pariser DM, Augustin M, Kerdel FA, et al. Drug survival of biologic therapy in a large, disease-based registry of patients with psoriasis: results from the Psoriasis Longitudinal Assessment and Registry (PSOLAR). J Eur Acad Dermatol Venereol. 2016;30:1148-58. doi: 10.1111/jdv.13611.
Shalom G, Cohen AD, Ziv M, Eran CB, Feldhamer I, Freud T, et al. Biologic drug survival in Israeli psoriasis patients. J Am Acad Dermatol. 2017;76:662-9.e1. doi: 10.1016/j.jaad.2016.10.033.
Armstrong AW, Bagel J, Van Voorhees AS, Robertson AD, Yamauchi PS. Combining biologic therapies with other systemic treatments in psoriasis: evidence-based, best-practice recommendations from the Medical
Board of the National Psoriasis Foundation. JAMA Dermatol. 2015;151:432-8. doi: 10.1001/jamadermatol.
Wolf P, Hofer A, Weger W, Posch-Fabian T, Gruber-Wackernagel A, Legat FJ. 311 nm ultraviolet B-accelerated response of psoriatic lesions in adalimumab-treated patients. Photodermatol Photoimmunol Photomed. 2011 ;27:186-9. doi: 10.1111/j.1600-0781.2011.00594.x
Wolf P, Hofer A, Legat FJ, Bretterklieber A, Weger W, Salmhofer W, et al. Treatment with 311-nm ultraviolet B accelerates and improves the clearance of psoriatic lesions in patients treated with etanercept. Br J Dermatol. 2009;160:186-9. doi: 10.1111/j.1365-2133.2008.08926.x.
Busard CI, Cohen AD, Wolf P, Gkalpakiotis S, Cazzaniga S, Stern RS, et al. Biologics combined with conventional systemic agents or phototherapy for the treatment of psoriasis: real-life data from PSONET registries. J Eur Acad Dermatol Venereol. 2018;32:245-253. doi: 10.1111/jdv.14583.
Lynde CW, Gupta AK, Guenther L, Poulin Y, Levesque A, Bissonnette R. A randomized study comparing
the combination of nbUVB and etanercept to etanercept monotherapy in patients with psoriasis who do not
exhibit an excellent response after 12 weeks of etanercept. J Dermatolog Treat. 2012;23:261-7. doi:
Park KK, Wu JJ, Koo J. A randomized, 'head-to-head' pilot study comparing the effects of etanercept monotherapy vs. etanercept and narrowband ultraviolet B (NB-UVB) phototherapy in obese psoriasis patients. J Eur Acad Dermatol Venereol. 2013;27:899-906. doi: 10.1111/j.1468-3083.2012.04611.x.
Ara M, Gracia T, Pastushenko E. Etanercept combined with systemic drugs or phototherapy for treatment of psoriasis Actas Dermosifiliogr. 2015;106:180-8.
Gambichler T, Tigges C, Scola N, Weber J, Skrygan M, Bechara FG,et al.. Etanercept plus narrowband ultraviolet B phototherapy of psoriasis is more effective than etanercept monotherapy at 6 weeks. Br J Dermatol. 2011;164:1383- 6. doi: 10.1111/j.1365-2133.2011.10358.x.
De Simone C, D'Agostino M, Capizzi R, Capponi A, Venier A, Caldarola G. Combined treatment with etanercept 50 mg once weekly and narrow-band ultraviolet B phototherapy in chronic plaque psoriasis. Eur J Dermatol. 2011; 21:568-72. doi: 10.1684/ejd.2011.1330.
Calzavara-Pinton PG, Sala R, Arisi M, Rossi MT, Venturini M, Ortel B.Synergism between narrowband ultraviolet B phototherapy and etanercept for the treatment of plaque-
type psoriasis. Br J Dermatol. 2013; 169:130-6. doi:10.1111/bjd.12277.
Bagel J. Adalimumab plus narrowband ultraviolet B light phototherapy for the treatment of moderate to severe psoriasis. J Drugs Dermatol. 2011 ;10:366-71.
Wolf P, Weger W, Legat FJ, Posch-Fabian T, Gruber-Wackernagel A, Inzinger M, et al. Treatment with 311-nm ultraviolet B enhanced response of psoriatic lesions in ustekinumab-treated patients: a randomized intraindividual trial. Br J Dermatol. 2012;166:147-53. doi: 10.1111/j.1365-2133.2011.10616.x.
Archier E, Devaux S, Castela E, Gallini A, Aubin F, Le Maître M, et al. Efficacy of psoralen UV-A therapy vs. narrowband UV-B therapy in chronic plaque psoriasis: a systematic literature review. J Eur Acad Dermatol Venereol. 2012;26:11-21. doi: 10.1111/j.1468-3083.2012.04519.x.
Gambichler T, Tigges C, Dith A, Skrygan M, Scola N, Altmeyer P, et al. Impact of etanercept treatment on ultraviolet B-induced inflammation, cell cycle regulation and DNA damage. Br J Dermatol. 2011;164:110-5. doi: 10.1111/j.1365-2133.2010.10099.x.
Patel RV, Clark LN, Lebwohl M, Weinberg JM. Treatments for psoriasis and the risk of malignancy. J Am
Acad Dermatol. 2009;60:1001-17. doi: 10.1016/j.jaad.2008.12.031.
Maeda A, Schneider SW, Kojima M, Beissert S, Schwarz T, Schwarz A. Enhanced photocarcinogenesis in interleukin-12-deficient mice. Cancer Res. 2006;66:2962-9.
Fulchiero GJ Jr, Salvaggio H, Drabick JJ, Staveley-O'Carroll K, Billingsley EM, Marks JG, et al. Eruptive latent metastatic melanomas after initiation of antitumor necrosis factor therapies. J Am Acad Dermatol. 2007;56:S65-7.
Kouklakis G, Efremidou EI, Pitiakoudis M, Liratzopoulos N, Polychronidis ACh. Development of primary malignant melanoma during treatment with a TNF-α antagonist for severe Crohn's disease: a case report and review of the hypothetical association between TNF-α blockers and cancer. Drug Des Devel Ther. 2013;7:195-9. doi: 10.2147/DDDT.S41889.
Ehmann LM, Tillack-Schreiber C, Brand S, Wollenberg A. Malignant melanoma during ustekinumab therapy of Crohn's disease. Inflamm Bowel Dis. 2012;18:E199-200. doi: 10.1002/ibd.21877.
Bovenschen HJ, Tjioe M, Vermaat H, de Hoop D, Witteman BM, Janssens RW, et al. Induction of eruptive benign melanocytic naevi by immune suppressive agents, including biologicals. Br J Dermatol. 2006;154:880-4.
Mercer LK, Askling J, Raaschou P, Dixon WG, Dreyer L, Hetland ML, et al. Risk of invasive melanoma in patients with rheumatoid arthritis treated with biologics: results from a collaborative project of 11 European biologic registers. Ann Rheum Dis. 2017;76:386-91. doi: 10.1136/annrheumdis-2016-209285.
Kubica AW, Brewer JD. Melanoma in immunosuppressed patients. Mayo Clin Proc. 2012t;87:991-1003. doi: 10.1016/j.mayocp.2012.04.018.
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