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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 7 | 16 |
| 2024 Octubre | 70 | 40 | 110 |
| 2024 Septiembre | 64 | 18 | 82 |
| 2024 Agosto | 80 | 43 | 123 |
| 2024 Julio | 68 | 34 | 102 |
| 2024 Junio | 84 | 23 | 107 |
| 2024 Mayo | 81 | 27 | 108 |
| 2024 Abril | 63 | 23 | 86 |
| 2024 Marzo | 71 | 23 | 94 |
| 2024 Febrero | 53 | 27 | 80 |
| 2024 Enero | 44 | 28 | 72 |
| 2023 Diciembre | 43 | 19 | 62 |
| 2023 Noviembre | 67 | 20 | 87 |
| 2023 Octubre | 66 | 19 | 85 |
| 2023 Septiembre | 72 | 27 | 99 |
| 2023 Agosto | 62 | 17 | 79 |
| 2023 Julio | 74 | 27 | 101 |
| 2023 Junio | 67 | 21 | 88 |
| 2023 Mayo | 93 | 23 | 116 |
| 2023 Abril | 73 | 27 | 100 |
| 2023 Marzo | 88 | 22 | 110 |
| 2023 Febrero | 82 | 25 | 107 |
| 2023 Enero | 50 | 35 | 85 |
| 2022 Diciembre | 58 | 49 | 107 |
| 2022 Noviembre | 36 | 30 | 66 |
| 2022 Octubre | 38 | 19 | 57 |
| 2022 Septiembre | 28 | 35 | 63 |
| 2022 Agosto | 30 | 42 | 72 |
| 2022 Julio | 30 | 34 | 64 |
| 2022 Junio | 23 | 29 | 52 |
| 2022 Mayo | 49 | 31 | 80 |
| 2022 Abril | 44 | 34 | 78 |
| 2022 Marzo | 50 | 43 | 93 |
| 2022 Febrero | 30 | 32 | 62 |
| 2022 Enero | 42 | 34 | 76 |
| 2021 Diciembre | 28 | 31 | 59 |
| 2021 Noviembre | 35 | 44 | 79 |
| 2021 Octubre | 51 | 45 | 96 |
| 2021 Septiembre | 36 | 45 | 81 |
| 2021 Agosto | 20 | 35 | 55 |
| 2021 Julio | 30 | 31 | 61 |
| 2021 Junio | 38 | 36 | 74 |
| 2021 Mayo | 25 | 39 | 64 |
| 2021 Abril | 55 | 72 | 127 |
| 2021 Marzo | 61 | 24 | 85 |
| 2021 Febrero | 43 | 28 | 71 |
| 2021 Enero | 21 | 27 | 48 |
| 2020 Diciembre | 26 | 22 | 48 |
| 2020 Noviembre | 21 | 24 | 45 |
| 2020 Octubre | 19 | 15 | 34 |
| 2020 Septiembre | 31 | 14 | 45 |
| 2020 Agosto | 13 | 14 | 27 |
| 2020 Julio | 32 | 14 | 46 |
| 2020 Junio | 27 | 20 | 47 |
| 2020 Mayo | 14 | 17 | 31 |
| 2020 Abril | 35 | 15 | 50 |
| 2020 Marzo | 18 | 20 | 38 |
| 2020 Febrero | 9 | 4 | 13 |
| 2020 Enero | 4 | 3 | 7 |
| 2019 Diciembre | 6 | 5 | 11 |
| 2019 Noviembre | 2 | 0 | 2 |
| 2019 Septiembre | 8 | 2 | 10 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 12 | 16 |
| 2019 Junio | 5 | 6 | 11 |
| 2019 Mayo | 6 | 7 | 13 |
| 2019 Abril | 3 | 6 | 9 |
| 2019 Marzo | 2 | 6 | 8 |
| 2019 Febrero | 4 | 3 | 7 |
| 2019 Enero | 2 | 1 | 3 |
| 2018 Diciembre | 0 | 2 | 2 |
| 2018 Noviembre | 2 | 4 | 6 |
| 2018 Octubre | 2 | 1 | 3 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Marzo | 1 | 1 | 2 |
| 2018 Febrero | 21 | 5 | 26 |
| 2018 Enero | 35 | 5 | 40 |
| 2017 Diciembre | 35 | 6 | 41 |
| 2017 Noviembre | 34 | 2 | 36 |
| 2017 Octubre | 30 | 2 | 32 |
| 2017 Septiembre | 33 | 7 | 40 |
| 2017 Agosto | 52 | 4 | 56 |
| 2017 Julio | 46 | 8 | 54 |
| 2017 Junio | 50 | 10 | 60 |
| 2017 Mayo | 55 | 7 | 62 |
| 2017 Abril | 38 | 12 | 50 |
| 2017 Marzo | 38 | 39 | 77 |
| 2017 Febrero | 21 | 5 | 26 |
| 2017 Enero | 11 | 13 | 24 |
| 2016 Diciembre | 39 | 4 | 43 |
| 2016 Noviembre | 49 | 2 | 51 |
| 2016 Octubre | 61 | 8 | 69 |
| 2016 Septiembre | 62 | 7 | 69 |
| 2016 Agosto | 38 | 9 | 47 |
| 2016 Julio | 29 | 7 | 36 |
| 2016 Junio | 13 | 9 | 22 |
| 2016 Mayo | 2 | 10 | 12 |
| 2016 Abril | 4 | 0 | 4 |
| 2016 Marzo | 3 | 1 | 4 |
| 2016 Febrero | 9 | 3 | 12 |
| 2016 Enero | 8 | 1 | 9 |
| 2015 Diciembre | 5 | 1 | 6 |
| 2015 Noviembre | 5 | 2 | 7 |
| 2015 Octubre | 2 | 3 | 5 |
| 2015 Septiembre | 1 | 1 | 2 |
| 2015 Agosto | 4 | 1 | 5 |
| 2015 Julio | 30 | 7 | 37 |
| 2015 Junio | 23 | 6 | 29 |
| 2015 Mayo | 44 | 4 | 48 |
| 2015 Abril | 36 | 5 | 41 |
| 2015 Marzo | 22 | 5 | 27 |
| 2015 Febrero | 27 | 1 | 28 |
| 2015 Enero | 14 | 4 | 18 |
| 2014 Diciembre | 26 | 7 | 33 |
| 2014 Noviembre | 15 | 3 | 18 |
| 2014 Octubre | 28 | 2 | 30 |
| 2014 Septiembre | 26 | 1 | 27 |
| 2014 Agosto | 16 | 6 | 22 |
| 2014 Julio | 16 | 8 | 24 |
| 2014 Junio | 23 | 6 | 29 |
| 2014 Mayo | 34 | 9 | 43 |
| 2014 Abril | 32 | 5 | 37 |
| 2014 Marzo | 13 | 6 | 19 |
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