title: Combining systemic retinoids with biologic agents for moderate to severe psoriasis.
abstract: BACKGROUND
  Moderate to severe psoriasis, which is defined as psoriasis affecting more than 20% of the body surface area, often requires a combination of therapies to achieve remission. Although numerous data exist regarding the use of acitretin and biologic agent therapy alone for psoriasis, little is known about the efficacy, safety, and tolerability of acitretin combined with biologic agents.
  
  
  METHODS
  Fifteen patients with psoriasis treated with concomitant acitretin and a biologic agent were identified, and their charts were reviewed for response to therapy, additional therapy necessary for disease management, side-effects, and laboratory abnormalities whilst on combination therapy. The Institutional Review Board did not require approval for this chart review.
  
  
  RESULTS
  Twenty-nine per cent of patients showed clearance of psoriasis, 43% of patients showed an improvement of 90%, 14% showed an improvement of 75%, and 7.1% showed no change. During treatment with acitretin and biologic agent, five patients required no adjunctive treatment. Three patients were able to stop narrow-band ultraviolet-B (UV-B) therapy after an average of 2.33 months of combination therapy. Only one patient continued to require phototherapy (UV-B) in addition to the biologic agent. Three patients developed squamous cell carcinoma (SCC) whilst on combination therapy, but all patients had a previous history of SCC. One patient developed non-Hodgkin's lymphoma after 3 years of etanercept and acitretin, and the etanercept was discontinued.
  
  
  CONCLUSIONS
  Acitretin combined with biologic agents offers a promising method of managing refractory psoriasis. More research is needed to determine the long-term safety and efficacy of this combination.
authors.affiliation: Department of Dermatology, Mount Sinai School of Medicine, New York, USA. elizabeth.smith@mssm.edu
authors.forename: Elizabeth C A
authors.initials: EC
authors.lastname: Smith
authors.forename: Christy
authors.initials: C
authors.lastname: Riddle
authors.forename: M Alan
authors.initials: MA
authors.lastname: Menter
authors.forename: Mark
authors.initials: M
authors.lastname: Lebwohl
mesh_terms: D017255:Acitretin / Q000008:administration & dosage* / Q000009:adverse effects; D000068879:Adalimumab; D000077944:Alefacept; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000009:adverse effects; D061067:Antibodies, Monoclonal, Humanized; D003879:Dermatologic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D004359:Drug Therapy, Combination; D000068800:Etanercept; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000008:administration & dosage / Q000009:adverse effects; D007155:Immunologic Factors / Q000008:administration & dosage* / Q000009:adverse effects; D000069285:Infliximab; D008228:Lymphoma, Non-Hodgkin / Q000209:etiology; D008297:Male; D008875:Middle Aged; D018307:Neoplasms, Squamous Cell / Q000209:etiology; D011565:Psoriasis / Q000188:drug therapy*; D018124:Receptors, Tumor Necrosis Factor / Q000008:administration & dosage; D011993:Recombinant Fusion Proteins / Q000008:administration & dosage / Q000009:adverse effects; D012189:Retrospective Studies; D012713:Serum Sickness / Q000209:etiology; D012878:Skin Neoplasms / Q000209:etiology; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D003879:Dermatologic Agents; D007074:Immunoglobulin G; D007155:Immunologic Factors; D018124:Receptors, Tumor Necrosis Factor; D011993:Recombinant Fusion Proteins; D000069285:Infliximab; D000077944:Alefacept; D000068879:Adalimumab; D017255:Acitretin; D000068800:Etanercept