Comparative effectiveness of less commonly used systemic monotherapies and common combination therapies for moderate to severe psoriasis in the clinical setting

J Am Acad Dermatol. 2014 Dec;71(6):1167-75. doi: 10.1016/j.jaad.2014.08.003. Epub 2014 Sep 24.


Background: The effectiveness of psoriasis therapies in real-world settings remains relatively unknown.

Objective: We sought to compare the effectiveness of less commonly used systemic therapies and commonly used combination therapies for psoriasis.

Methods: This was a multicenter cross-sectional study of 203 patients with plaque psoriasis receiving less common systemic monotherapy (acitretin, cyclosporine, or infliximab) or common combination therapies (adalimumab, etanercept, or infliximab and methotrexate) compared with 168 patients receiving methotrexate evaluated at 1 of 10 US outpatient dermatology sites participating in the Dermatology Clinical Effectiveness Research Network.

Results: In adjusted analyses, patients on acitretin (relative response rate 2.01; 95% confidence interval [CI] 1.18-3.41), infliximab (relative response rate 1.93; 95% CI 1.26-2.98), adalimumab and methotrexate (relative response rate 3.04; 95% CI 2.12-4.36), etanercept and methotrexate (relative response rate 2.22; 95% CI 1.25-3.94), and infliximab and methotrexate (relative response rate 1.72; 95% CI 1.10-2.70) were more likely to have clear or almost clear skin compared with patients on methotrexate. There were no differences among treatments when response rate was defined by health-related quality of life.

Limitations: Single time point assessment may result in overestimation of effectiveness.

Conclusions: The efficacy of therapies in clinical trials may overestimate their effectiveness as used in clinical practice. Although physician-reported relative response rates were different among therapies, absolute differences were small and did not correspond to differences in patient-reported outcomes.

Keywords: Dermatology Life Quality Index; Physician Global Assessment; biologics; combination therapy; comparative effectiveness; psoriasis; quality of life; systemic treatments.

Publication types

  • Comparative Study
  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acitretin / therapeutic use
  • Adalimumab
  • Adult
  • Aged
  • Anti-Inflammatory Agents / therapeutic use
  • Antibodies, Monoclonal / therapeutic use
  • Antibodies, Monoclonal, Humanized / therapeutic use
  • Cross-Sectional Studies
  • Cyclosporine / therapeutic use
  • Dermatologic Agents / therapeutic use
  • Drug Therapy, Combination
  • Etanercept
  • Female
  • Humans
  • Immunoglobulin G / therapeutic use
  • Infliximab
  • Keratolytic Agents / therapeutic use
  • Male
  • Methotrexate / therapeutic use*
  • Middle Aged
  • Psoriasis / drug therapy*
  • Receptors, Tumor Necrosis Factor / therapeutic use
  • Severity of Illness Index*
  • Young Adult


  • Anti-Inflammatory Agents
  • Antibodies, Monoclonal
  • Antibodies, Monoclonal, Humanized
  • Dermatologic Agents
  • Immunoglobulin G
  • Keratolytic Agents
  • Receptors, Tumor Necrosis Factor
  • Cyclosporine
  • Infliximab
  • Adalimumab
  • Acitretin
  • Etanercept
  • Methotrexate