INTRODUCTION
Psoriasis is a burdensome chronic, relapsing and remitting immune-mediated inflammatory skin condition requiring long term treatment. The worldwide prevalence of psoriasis is 2-3%.1 Biologic therapy is the preferred method for treating moderate to severe psoriasis unresponsive to localized topical therapies, oral agents, and phototherapy.2 Combination therapy (CT) with biologics is commonly chosen when monotherapy is inefficient and to reduce adverse events.3 CT with apremilast is less commonly used to treat psoriasis although it offers promising results. Apremilast was FDA approved in 2014 as an oral monotherapy for the treatment of moderate to severe psoriasis.4 Recommended apremilast dosage is up-titration to 30 mg twice daily. There is a gap in clinical research about using apremilast CT for recalcitrant psoriasis so in this literature review, we aim to assess scientific literature for apremilast CT in treating moderate to severe psoriasis.
MATERIALS AND METHODS
The review is based on a literature search performed by one reviewer (M.I.) using the PubMed database on April 7, 2020. Key search terms included apremilast, psoriasis, topicals, oral agents, biologics, combined therapy, and combination therapy.
The reviewer performed subsequent data extraction, evaluation, and synthesis of original clinical research articles and case reports between the years 2015-2019. Included articles used apremilast in combination with oral agents, topicals, biologics, and/or phototherapy to treat psoriasis. Articles were excluded if the pathology did not include psoriasis, treatment did not include concurrent combination therapy with apremilast, information on agents used for combination therapy was unavailable or were review papers. The online literature search yielded 262 original articles. A total of 17 articles met the selection criteria and were included (Figure 1).
Study Characteristics
Clinical efficacy of apremilast CT was assessed in 1 randomized controlled trial, 2 nonrandomized interventional studies, 5 retrospective chart reviews, and 9 case reports from years 2015 to 2019. A total of 617 patients were treated using apremilast CT. Patients had plaque psoriasis with the exception of 2 patients with generalized pustular psoriasis and Acrodermatitis continua of Hallopeau (n=1), and psoriasis verrucosa (n=1). The mean patient age was 51.7 years (range 18-74). Mainly, patients with moderate to severe disease were included. Patients had comorbidities such as psoriatic arthritis, autoimmune diseases, and other chronic conditions (eg, type 2 diabetes mellitus).
The reviewer performed subsequent data extraction, evaluation, and synthesis of original clinical research articles and case reports between the years 2015-2019. Included articles used apremilast in combination with oral agents, topicals, biologics, and/or phototherapy to treat psoriasis. Articles were excluded if the pathology did not include psoriasis, treatment did not include concurrent combination therapy with apremilast, information on agents used for combination therapy was unavailable or were review papers. The online literature search yielded 262 original articles. A total of 17 articles met the selection criteria and were included (Figure 1).
Study Characteristics
Clinical efficacy of apremilast CT was assessed in 1 randomized controlled trial, 2 nonrandomized interventional studies, 5 retrospective chart reviews, and 9 case reports from years 2015 to 2019. A total of 617 patients were treated using apremilast CT. Patients had plaque psoriasis with the exception of 2 patients with generalized pustular psoriasis and Acrodermatitis continua of Hallopeau (n=1), and psoriasis verrucosa (n=1). The mean patient age was 51.7 years (range 18-74). Mainly, patients with moderate to severe disease were included. Patients had comorbidities such as psoriatic arthritis, autoimmune diseases, and other chronic conditions (eg, type 2 diabetes mellitus).
