Treatment of psoriatic arthritis and recalcitrant skin disease with combination therapy

Psoriasis and psoriatic arthritis (PsA) are chronic inflammatory disorders. Efalizumab targets several T-cell interactions central to psoriasis immunopathogenesis. Etanercept and infliximab are antitumor necrosis factor (anti-TNF) agents that modify the inflammatory and cell-mediated immune responses involved in the pathogenesis of psoriasis and PsA. All 3 agents are approved for the treatment of plaque psoriasis, and etanercept and infliximab are also approved for the treatment of PsA. Twenty patients with psoriasis and PsA have been successfully treated with a combination of efalizumab (1 mg/kg/wk) and etanercept (25 mg or 50 mg/wk) or infliximab (5 to 6 mg/kg). To date, no serious adverse events have been reported. Combination therapy was well tolerated and effectively controlled both skin disease and arthritis. The complementary activity of efalizumab with an anti-TNF agent is most likely attributable to their differing mechanisms of action. Further investigation is warranted.