INTRODUCTION
Psoriasis is a chronic, immune-mediated skin disease that affects approximately 3% of the population in the US.1,2 Moderate to severe psoriasis is associated with a number of medical comorbidities, including but not limited to psoriatic arthritis, cardiovascular disease, metabolic syndrome, and depression.3,4 Psoriasis also impair patients’ quality of life,4,5 with an impact similar to those by other serious chronic diseases, such as cancer or cardiovascular diseases.5
Among different subtypes of psoriasis, plaque psoriasis is the most common form, characterized by a raised silvery scale with underlying erythema, itching, and discomfort. Although there is no cure for the disease, a variety of treatment options including topical, phototherapy, oral, and biologic therapies are available to manage clinical symptoms, with topical medication usually used to treat mild psoriasis and the latter three to treat moderate to severe psoriasis.6 However, not all patients can achieve adequate responses (75% reduction in psoriasis area severity index [PASI] score6) to monotherapies. Combination therapy with different modalities has been ultilized.7-11 Therapies with different mechanisms of action could generate a synergistic effect, thus enhancing the treatment effect without the need of increasing dosages and subsequently minimizing adverse events.9,11,12
Despite their established efficacy in treating psoriasis,13 many patients are reluctant to receive biologic agents due to safety and tolerability concerns, anxiety or fear of injection, inconvenience in administration, or loss of effectiveness over time.14 Patients may be hesitant to use biologics by the reported adverse effects such as tuberculosis, inflammatory bowel disease, serious infections, or depression with specific biologics.15 Non-biological systemic medications remain widely used with comparatively increased availability and ease of administration.16 Apremilast is an oral systemic agent that inhibits phosphodiesterase 4.17 Two phase 3, randomized, controlled studies showed that apremilast effectively controlled moderate to severe plaque psoriasis with acceptable tolerability and improved quality of life.18-20 However, the proportions of patients who achieved PASI 75 response at week 16 were 33% (ESTEEM 1)18 and 29% (ESTEEM 2)19 in the studies, showing the vast majority of the patients did not have sufficient improvement with apremilast monotherapy.
Topical therapies combined with systemic medications are frequently used to treat psoriasis patients with BSA >10%.8 Adjunctive topical therapy has been shown to improve the efficacy of biologics, systemic agents, and phototherapy in treating moderate to severe psoriasis without causing
Among different subtypes of psoriasis, plaque psoriasis is the most common form, characterized by a raised silvery scale with underlying erythema, itching, and discomfort. Although there is no cure for the disease, a variety of treatment options including topical, phototherapy, oral, and biologic therapies are available to manage clinical symptoms, with topical medication usually used to treat mild psoriasis and the latter three to treat moderate to severe psoriasis.6 However, not all patients can achieve adequate responses (75% reduction in psoriasis area severity index [PASI] score6) to monotherapies. Combination therapy with different modalities has been ultilized.7-11 Therapies with different mechanisms of action could generate a synergistic effect, thus enhancing the treatment effect without the need of increasing dosages and subsequently minimizing adverse events.9,11,12
Despite their established efficacy in treating psoriasis,13 many patients are reluctant to receive biologic agents due to safety and tolerability concerns, anxiety or fear of injection, inconvenience in administration, or loss of effectiveness over time.14 Patients may be hesitant to use biologics by the reported adverse effects such as tuberculosis, inflammatory bowel disease, serious infections, or depression with specific biologics.15 Non-biological systemic medications remain widely used with comparatively increased availability and ease of administration.16 Apremilast is an oral systemic agent that inhibits phosphodiesterase 4.17 Two phase 3, randomized, controlled studies showed that apremilast effectively controlled moderate to severe plaque psoriasis with acceptable tolerability and improved quality of life.18-20 However, the proportions of patients who achieved PASI 75 response at week 16 were 33% (ESTEEM 1)18 and 29% (ESTEEM 2)19 in the studies, showing the vast majority of the patients did not have sufficient improvement with apremilast monotherapy.
Topical therapies combined with systemic medications are frequently used to treat psoriasis patients with BSA >10%.8 Adjunctive topical therapy has been shown to improve the efficacy of biologics, systemic agents, and phototherapy in treating moderate to severe psoriasis without causing
