Case and Research Letter
Restoration of Response to Ustekinumab With Narrowband UV-B Phototherapy
Recuperación de la respuesta a ustekinumab mediante fototerapia con ultravioleta B de banda estrecha
P. Soro Martínez, I. Belinchón Romero
, M.P. Arribas Granados
Corresponding author
Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain
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Soro Martínez, I. Belinchón Romero, M.P. Arribas Granados" "autores" => array:3 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Soro Martínez" ] 1 => array:4 [ "nombre" => "I." "apellidos" => "Belinchón Romero" "email" => array:1 [ 0 => "belinchon_isa@gva.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "M.P." "apellidos" => "Arribas Granados" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recuperación de la respuesta a ustekinumab mediante fototerapia con ultravioleta B de banda estrecha" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 727 "Ancho" => 1001 "Tamanyo" => 132845 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Patient 1. Recurrence of psoriasis 30 weeks after initiation of ustekinumab (PASI, 9.8). B, Patient 1. PASI 75 after combining 17 sessions of narrowband UV-B therapy (12.9<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>) with ustekinumab (PASI, 2.1). PASI indicates Psoriasis Area and Severity Index.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The various approaches approved for the treatment of moderate and severe forms of psoriasis include phototherapy, photochemotherapy, classic systemic agents, and biologic agents. These approaches may be used in monotherapy, in combination with topical agents, or in combination with each other. The choice of therapy should be based on the individual characteristics of the patient and the disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We present 2 cases of moderate to severe psoriasis treated with the combination of ustekinumab and narrowband UV-B phototherapy during secondary loss of response to the drug.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Patient 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">Patient 1 was a 37-year-old man weighing 90<span class="elsevierStyleHsp" style=""></span>kg. He was a smoker (20 pack-years) and had no relevant past medical history. He had moderate to severe psoriasis that had begun 11 years earlier and for which he had received treatment with acitretin, ciclosporin, infliximab, and etanercept. This approach was partially successful. A new flare-up of psoriasis was treated with ustekinumab 45<span class="elsevierStyleHsp" style=""></span>mg according to the standard regimen, and the initial response was excellent: his Psoriasis Area and Severity Index (PASI) fell from 10.2 to 1.2 (improvement of 90%), which was maintained until week 30, when he experienced a relapse (PASI, 9.8) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), with no increase in body weight. At this point, phototherapy was combined with ustekinumab. After 17 sessions of narrowband UV-B phototherapy and a cumulative dose of 12.9<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>, his psoriasis improved considerably, and his PASI fell to 2.1 (improvement of 75%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The patient remained stable and recurrence-free after 5 months of ustekinumab in monotherapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Patient 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">Patient 2 was a 57-year-old woman weighing 87<span class="elsevierStyleHsp" style=""></span>kg with a previous history of arterial hypertension, positional vertigo, and anxiety. She was receiving treatment with betahistine, amiloride/hydrochlorothiazide, tetrazepam, and atenolol (indispensable for control of her arterial hypertension). She had a 15-year history of moderate to severe psoriasis and, during that time, she had received several treatments (methotrexate, infliximab, adalimumab, and etanercept), to which the response was poor or short-term. Her initial response to ustekinumab 45<span class="elsevierStyleHsp" style=""></span>mg with the usual regimen was good (PASI 10.6 to PASI 4.2, improvement of 50%-75%), although at 64 weeks of treatment her condition worsened (PASI 7.8) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), with no change in body weight; therefore, ustekinumab was combined with narrowband UV-B phototherapy. After 16 sessions and a cumulative dose of 15<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>, her psoriasis improved considerably, and her PASI fell to 0.6 (improvement of 90%) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), which remained stable with ustekinumab in monotherapy after 3 months of follow-up.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Biologic agents constitute a major advance in the treatment of moderate to severe psoriasis. Although they are all efficacious in the short term, the response is lost over time in some cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The PHOENIX 1 study showed that continuous therapy with ustekinumab maintained the clinical response in most patients over time.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Overall, almost 80% continued to receive treatment until the third year, and the number of interruptions associated with efficacy was low (45<span class="elsevierStyleHsp" style=""></span>mg [7.9%]; 90<span class="elsevierStyleHsp" style=""></span>mg [4.2%]). Most patients had a lasting PASI 75 (45<span class="elsevierStyleHsp" style=""></span>mg [62.7%]; 90<span class="elsevierStyleHsp" style=""></span>mg [72.2%]), and 84% maintained a response that was equal to or greater than PASI 50.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although it seems that there was no major decrease in response over time in the study population as a whole, it is important to identify this subgroup and prepare rescue strategies, such as reduction in the administration interval (eg, 12 to 8 weeks) or combination with other topical or systemic agents or phototherapy.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Several clinical studies have found that combination with narrowband UV-B phototherapy improves the efficacy of some tumor necrosis alfa (TNF-α) factor inhibitors such as etanercept<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> and adalimumab.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> A recent study based on a small clinical series revealed similar findings in patients treated with ustekinumab,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> as in the 2 cases described above.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical improvement in psoriasis treated with narrowband UV-B phototherapy is linked to suppression of the signaling pathways of type 17 helper T cells and types I and II interferons, which play a key role in pathogenesis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The modifying effects of phototherapy also have an effect on the antigen-presenting function and direct apoptosis of T lymphocytes.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given that some experimental studies have shown how combination therapy with anti-TNF-α agents can increase the risk of photocarcinogenesis,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> the combination of biologic agents and phototherapy should be administered with caution and only in selected patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">To conclude, narrowband UV-B phototherapy could be a good alternative for restoration of the response to ustekinumab in selected cases of moderate to severe psoriasis.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Patient 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Patient 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Soro Martínez P, Belinchón Romero I, Arribas Granados MP. Recuperación de la respuesta a ustekinumab mediante fototerapia con ultravioleta B de banda estrecha. Actas Dermosifiliogr. 2014;105:200–202.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 727 "Ancho" => 1001 "Tamanyo" => 132845 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Patient 1. Recurrence of psoriasis 30 weeks after initiation of ustekinumab (PASI, 9.8). B, Patient 1. PASI 75 after combining 17 sessions of narrowband UV-B therapy (12.9<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>) with ustekinumab (PASI, 2.1). PASI indicates Psoriasis Area and Severity Index.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 688 "Ancho" => 1000 "Tamanyo" => 99599 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patient 2. Worsening of psoriasis at 64 weeks after initiation of ustekinumab (Psoriasis Area and Severity Index, 7.8).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 611 "Ancho" => 1000 "Tamanyo" => 90621 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient 2. Psoriasis Area and Severity Index 90 response with the combination of ustekinumab and narrowband UV-B phototherapy (15<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span> in 16 sessions).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Directrices españolas basadas en la evidencia para el tratamiento de la psoriasis moderada a grave con agentes biológicos" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Puig" 1 => "J.M. Carrascosa" 2 => "E. Daudén" 3 => "J.L. Sánchez-Carazo" 4 => "C. Ferrándiz" 5 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 7 | 17 |
| 2024 October | 70 | 40 | 110 |
| 2024 September | 64 | 18 | 82 |
| 2024 August | 80 | 43 | 123 |
| 2024 July | 68 | 34 | 102 |
| 2024 June | 84 | 23 | 107 |
| 2024 May | 81 | 27 | 108 |
| 2024 April | 63 | 23 | 86 |
| 2024 March | 71 | 23 | 94 |
| 2024 February | 53 | 27 | 80 |
| 2024 January | 44 | 28 | 72 |
| 2023 December | 43 | 19 | 62 |
| 2023 November | 67 | 20 | 87 |
| 2023 October | 66 | 19 | 85 |
| 2023 September | 72 | 27 | 99 |
| 2023 August | 62 | 17 | 79 |
| 2023 July | 74 | 27 | 101 |
| 2023 June | 67 | 21 | 88 |
| 2023 May | 93 | 23 | 116 |
| 2023 April | 73 | 27 | 100 |
| 2023 March | 88 | 22 | 110 |
| 2023 February | 82 | 25 | 107 |
| 2023 January | 50 | 35 | 85 |
| 2022 December | 58 | 49 | 107 |
| 2022 November | 36 | 30 | 66 |
| 2022 October | 38 | 19 | 57 |
| 2022 September | 28 | 35 | 63 |
| 2022 August | 30 | 42 | 72 |
| 2022 July | 30 | 34 | 64 |
| 2022 June | 23 | 29 | 52 |
| 2022 May | 49 | 31 | 80 |
| 2022 April | 44 | 34 | 78 |
| 2022 March | 50 | 43 | 93 |
| 2022 February | 30 | 32 | 62 |
| 2022 January | 42 | 34 | 76 |
| 2021 December | 28 | 31 | 59 |
| 2021 November | 35 | 44 | 79 |
| 2021 October | 51 | 45 | 96 |
| 2021 September | 36 | 45 | 81 |
| 2021 August | 20 | 35 | 55 |
| 2021 July | 30 | 31 | 61 |
| 2021 June | 38 | 36 | 74 |
| 2021 May | 25 | 39 | 64 |
| 2021 April | 55 | 72 | 127 |
| 2021 March | 61 | 24 | 85 |
| 2021 February | 43 | 28 | 71 |
| 2021 January | 21 | 27 | 48 |
| 2020 December | 26 | 22 | 48 |
| 2020 November | 21 | 24 | 45 |
| 2020 October | 19 | 15 | 34 |
| 2020 September | 31 | 14 | 45 |
| 2020 August | 13 | 14 | 27 |
| 2020 July | 32 | 14 | 46 |
| 2020 June | 27 | 20 | 47 |
| 2020 May | 14 | 17 | 31 |
| 2020 April | 35 | 15 | 50 |
| 2020 March | 18 | 20 | 38 |
| 2020 February | 9 | 4 | 13 |
| 2020 January | 4 | 3 | 7 |
| 2019 December | 6 | 5 | 11 |
| 2019 November | 2 | 0 | 2 |
| 2019 September | 8 | 2 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 12 | 16 |
| 2019 June | 5 | 6 | 11 |
| 2019 May | 6 | 7 | 13 |
| 2019 April | 3 | 6 | 9 |
| 2019 March | 2 | 6 | 8 |
| 2019 February | 4 | 3 | 7 |
| 2019 January | 2 | 1 | 3 |
| 2018 December | 0 | 2 | 2 |
| 2018 November | 2 | 4 | 6 |
| 2018 October | 2 | 1 | 3 |
| 2018 September | 1 | 0 | 1 |
| 2018 March | 1 | 1 | 2 |
| 2018 February | 21 | 5 | 26 |
| 2018 January | 35 | 5 | 40 |
| 2017 December | 35 | 6 | 41 |
| 2017 November | 34 | 2 | 36 |
| 2017 October | 30 | 2 | 32 |
| 2017 September | 33 | 7 | 40 |
| 2017 August | 52 | 4 | 56 |
| 2017 July | 46 | 8 | 54 |
| 2017 June | 50 | 10 | 60 |
| 2017 May | 55 | 7 | 62 |
| 2017 April | 38 | 12 | 50 |
| 2017 March | 38 | 39 | 77 |
| 2017 February | 21 | 5 | 26 |
| 2017 January | 11 | 13 | 24 |
| 2016 December | 39 | 4 | 43 |
| 2016 November | 49 | 2 | 51 |
| 2016 October | 61 | 8 | 69 |
| 2016 September | 62 | 7 | 69 |
| 2016 August | 38 | 9 | 47 |
| 2016 July | 29 | 7 | 36 |
| 2016 June | 13 | 9 | 22 |
| 2016 May | 2 | 10 | 12 |
| 2016 April | 4 | 0 | 4 |
| 2016 March | 3 | 1 | 4 |
| 2016 February | 9 | 3 | 12 |
| 2016 January | 8 | 1 | 9 |
| 2015 December | 5 | 1 | 6 |
| 2015 November | 5 | 2 | 7 |
| 2015 October | 2 | 3 | 5 |
| 2015 September | 1 | 1 | 2 |
| 2015 August | 4 | 1 | 5 |
| 2015 July | 30 | 7 | 37 |
| 2015 June | 23 | 6 | 29 |
| 2015 May | 44 | 4 | 48 |
| 2015 April | 36 | 5 | 41 |
| 2015 March | 22 | 5 | 27 |
| 2015 February | 27 | 1 | 28 |
| 2015 January | 14 | 4 | 18 |
| 2014 December | 26 | 7 | 33 |
| 2014 November | 15 | 3 | 18 |
| 2014 October | 28 | 2 | 30 |
| 2014 September | 26 | 1 | 27 |
| 2014 August | 16 | 6 | 22 |
| 2014 July | 16 | 8 | 24 |
| 2014 June | 23 | 6 | 29 |
| 2014 May | 34 | 9 | 43 |
| 2014 April | 32 | 5 | 37 |
| 2014 March | 13 | 6 | 19 |
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