Although an increasing number of studies show support for combination therapy with biologics and systemic agents or phototherapy, data is now emerging indicating selective biologics may be effective monotherapy.

Combination systemic therapy may optimize treatment outcomes because of the potential of additive or synergistic efficacy and the dose of individual agents may be reduced, which lessens the toxicity and improves tolerability and patient compliance.

Studies have shown that up to 30% of patients receiving a tumor necrosis factor (TNF)-alpha antagonist also receive concomitant treatment with a traditional systemic agent such as methotrexate cyclosporine or retinoids. However, there are limitations to these findings.

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In a recent issue of the American Journal of Clinical Dermatology, Jennifer C. Cather, MD, and Jeffrey J. Crowley, MD, published their review of available evidence on the efficacy and safety of combining biologic agents with systemic therapies or phototherapy, and the combination of certain biologics as monotherapy.

The investigators reported that many patients with psoriasis taking biologic and systemic therapies still do not achieve the desired outcome, have a prolonged time to response, or fail to maintain efficacy improvements over time. Tolerability may also be an issue.

Limited data exist on the concomitant administration of two biologic agents targeting TNF-alpha and interleukins (ILs)-12/23, and additional research is needed.

Several biologic therapies for future potential use as monotherapy are in phase 2 or 3 trials and include those that target IL-17A or its receptor, IL-23, and T cells. It is currently unknown how these therapies will fit into the psoriasis treatment paradigm, but the authors suggest these agents offer the potential for selective targeting of key processes in the pathogenesis of psoriasis.

“These agents selectively target key processes in the pathogenesis of psoriasis and thus may offer better efficacy than current biologic and systemic therapies. Therefore, these agents may allow more patients and prescribers to meet their psoriasis management goals without the need to augment treatment regimens with additional agents,” wrote the authors.


  1. Cather JC. Am J Clin Dermatol. 2014;15:467–478.


Cather has served as a speaker or consultant for AbbVie, Janssen, Leo, and Novartis. She has served as an investigator in clinical trials for Amgen, Celgene, Galderma, Lilly, Merck, Novartis, Pfizer, and Tolmar. She owns no stock and has no ownership interest in any pharmaceutical company.