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Topical Treatments For Chronic Plaque Psoriasis.

A. Mason, J. Mason, M. Cork, G. Dooley, H. Hancock
Published 2013 · Medicine

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BACKGROUND Chronic plaque psoriasis is the most common type of psoriasis, and it is characterised by redness, thickness, and scaling. First-line management of chronic plaque psoriasis is with topical treatments, including vitamin D analogues, topical corticosteroids, tar-based preparations, dithranol, salicylic acid, and topical retinoids. OBJECTIVES To compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis, relative to placebo, and to similarly compare vitamin D analogues (used alone or in combination) with other topical treatments. SEARCH METHODS We updated our searches of the following databases to February 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2011, Issue 2), MEDLINE (from 1948), EMBASE (from 1980), Science Citation Index (from 2008), Conference Proceedings Citation Index - Science (from 2008), BIOSIS (from 1993), Dissertation Abstracts via DialogClassic (all publication years), and Inside Conferences (all publication years).We identified ongoing and unpublished studies from the UK Clinical Research Network Study Portfolio and the metaRegister of Controlled Trials. We checked the bibliographies of published studies and reviews for further references to relevant trials, and we contacted trialists and companies for information about newly published studies.A separate search for adverse effects was undertaken in February 2011 using MEDLINE and EMBASE (from 2005).Final update searches for both RCTs and adverse effects were undertaken in August 2012. Although it has not been possible to incorporate RCTs and adverse effects studies identified through these final searches within this review, we will incorporate these into the next update. SELECTION CRITERIA Randomised trials comparing active topical treatments against placebo or against vitamin D analogues (used alone or in combination) in people with chronic plaque psoriasis. DATA COLLECTION AND ANALYSIS One author extracted study data and assessed study quality. A second author checked these data. We routinely contacted trialists and companies for missing data. We also extracted data on withdrawals and on local and systemic adverse events. We defined long-term trials as those with a duration of at least 24 weeks. MAIN RESULTS This update added 48 trials and provided evidence on 7 new active treatments. In total, the review included 177 randomised controlled trials, with 34,808 participants, including 26 trials of scalp psoriasis and 6 trials of inverse psoriasis, facial psoriasis, or both. The number of included studies counted by Review Manager (RevMan) is higher than these figures (190) because we entered each study reporting a placebo and an active comparison into the 'Characteristics of included studies' table as 2 studies.When used on the body, most vitamin D analogues were significantly more effective than placebo, with the standardised mean difference (SMD) ranging from -0.67 (95% CI -1.04 to -0.30; 1 study, 119 participants) for twice-daily becocalcidiol to SMD -1.66 (95% CI -2.66 to -0.67; 1 study, 11 participants) for once-daily paricalcitol. On a 6-point global improvement scale, these effects translate into 0.8 and 1.9 points, respectively. Most corticosteroids also performed better than placebo; potent corticosteroids (SMD -0.89; 95% CI -1.06 to -0.72; I² statistic = 65.1%; 14 studies, 2011 participants) had smaller benefits than very potent corticosteroids (SMD -1.56; 95% CI -1.87 to -1.26); I² statistic = 81.7%; 10 studies, 1264 participants). On a 6-point improvement scale, these benefits equate to 1.0 and 1.8 points, respectively. Dithranol, combined treatment with vitamin D/corticosteroid, and tazarotene all performed significantly better than placebo.Head-to-head comparisons of vitamin D for psoriasis of the body against potent or very potent corticosteroids had mixed findings. For both body and scalp psoriasis, combined treatment with vitamin D and corticosteroid performed significantly better than vitamin D alone or corticosteroid alone. Vitamin D generally performed better than coal tar, but findings relative to dithranol were mixed. When applied to psoriasis of the scalp, vitamin D was significantly less effective than both potent corticosteroids and very potent corticosteroids. Indirect evidence from placebo-controlled trials supported these findings.For both body and scalp psoriasis, potent corticosteroids were less likely than vitamin D to cause local adverse events, such as burning or irritation. Combined treatment with vitamin D/corticosteroid on either the body or the scalp was tolerated as well as potent corticosteroids, and significantly better than vitamin D alone. Only 25 trials assessed clinical cutaneous dermal atrophy; few cases were detected, but trials reported insufficient information to determine whether assessment methods were robust. Clinical measurements of dermal atrophy are insensitive and detect only the most severe cases. No comparison of topical agents found a significant difference in systemic adverse effects. AUTHORS' CONCLUSIONS Corticosteroids perform at least as well as vitamin D analogues, and they are associated with a lower incidence of local adverse events. However, for people with chronic plaque psoriasis receiving long-term treatment with corticosteroids, there remains a lack of evidence about the risk of skin dermal atrophy. Further research is required to inform long-term maintenance treatment and provide appropriate safety data.
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S. Y. Yip (1984)
10.1177/030006058301100208
Effect of Salicylic Acid on the Activity of Betamethasone-17,21-Dipropionate in the Treatment of Erythematous Squamous Dermatoses
Robert Elic (1983)
Better patient compliance in psoriasis.
T. Chu (2000)
10.1046/j.1365-2133.2001.04075.x
Rationale for use and clinical responsiveness of hexafluoro‐1,25‐dihydroxyvitamin D3 for the treatment of plaque psoriasis: a pilot study
C. Durakovic (2001)
10.1159/000096069
Efficacy Results of a 52-Week, Randomised, Double-Blind, Safety Study of a Calcipotriol/Betamethasone Dipropionate Two-Compound Product (Daivobet®/Dovobet®/Taclonex®) in the Treatment of Psoriasis Vulgaris
K. Kragballe (2006)
Economic analyses of the treatment of psoriasis
J. Lambert (1996)
10.1016/0926-9959(95)96533-E
Calcipotriol cream and concurrent corticosteroids in psoriasis
P. Kerkhof (1995)
10.1097/00045391-200603000-00007
Treatment of Mild to Moderate Psoriasis with Reliéva, a Mahonia aquifolium Extract—A Double-Blind, Placebo-Controlled Study
S. Bernstein (2006)
Clobetasol propionate shampoo 0.05%: a new option to treat patients with moderate to severe scalp psoriasis.
M. Jarratt (2004)
10.3109/09546639209088718
1α,25-dihydroxyvitamin D3 (calcitriol) ointment in psoriasis
A. Langner (1992)
10.2165/11530380-000000000-00000
Efficacy and Tolerability of a Cosmetically Acceptable Coal Tar Solution in the Treatment of Moderate Plaque Psoriasis
M. Alora-Palli (2010)
10.2340/0001555574398402
Efficacy and safety of the 20-epi-vitamin D3 analogue KH 1060 in the topical therapy of psoriasis: results of a dose-ranging study.
K. Kragballe (1994)
10.1111/j.1468-3083.2007.02425.x
Adherence to treatment in patients with psoriasis vulgaris: Turkish experience
G. Gokdemir (2008)
Long-term efficacy and safety of once daily treatment of chronic plaque psoriasis with tacalcitol ointment
P. Kerkhof (1997)
10.1046/j.1365-4362.2001.01067-7.x
Duration of improvement in psoriasis after treatment with tazarotene 0.1% gel plus clobetasol propionate 0.05% ointment: comparison of maintenance treatments
M. Lebwohl (2001)
10.1038/ng.694
A genome-wide association study identifies new psoriasis susceptibility loci and an interaction between HLA-C and ERAP1
A. Strange (2010)
10.1002/14651858.CD011571
Antistreptococcal interventions for guttate and chronic plaque psoriasis
Gwendy Dupire (2015)
10.1159/000323408
Calcipotriol plus Betamethasone Dipropionate Gel Compared with Tacalcitol Ointment and the Gel Vehicle Alone in Patients with Psoriasis Vulgaris: A Randomized, Controlled Clinical Trial
R. Langley (2011)
10.1177/120347540000400302
Per-Gram Cost of Medication is by Itself a Poor Indicator for Comparing Costs of Different Psoriasis Treatments: A Retrospective Cohort Study of the Cost of Psoriasis Treatment with Topical Corticosteroids versus Topical Calcipotriene
S. Feldman (2000)
10.1111/j.1365-2230.1993.tb01018.x
Occlusion enhances the efficacy of topical calcipotriol in the treatment of psoriasis vulgaris
J. Bourke (1993)
10.1046/j.1365-2133.2002.04967.x
Efficacy and safety of a new combination of calcipotriol and betamethasone dipropionate (once or twice daily) compared to calcipotriol (twice daily) in the treatment of psoriasis vulgaris: a randomized, double‐blind, vehicle‐controlled clinical trial
L. Guenther (2002)
10.1046/j.1365-2133.1999.03207.x
Quality of life, health‐state utilities and willingness to pay in patients with psoriasis and atopic eczema
L. Lundberg (1999)
10.12968/HMED.2007.68.5.23333
Psoriasis: maximizing topical treatment concordance.
G. Gupta (2007)
10.1111/j.1365-2133.1993.tb00237.x
Topical calcitriol in the treatment of chronic plaque psoriasis: a double‐blind study
A. Langner (1993)
10.1159/000068469
Treatment of Psoriatic Nails with Topical Cyclosporin: A Prospective, Randomized Placebo-Controlled Study
S. Cannavó (2003)
10.1016/J.JAAD.2007.04.005
Adherence to topical therapy increases around the time of office visits.
S. Feldman (2007)
The benefits, costs and risks of topical tar preparations in the treatment of psoriasis: considerations of cost effectiveness.
R. Stern (1988)
10.1016/S0190-9622(89)70082-7
Preatrophy: covert sign of thinned skin.
H. Katz (1989)
10.1016/S0190-9622(96)90434-X
Topical calcipotriene has no short-term effect on calcium and bone metabolism of patients with psoriasis.
C. Guzzo (1996)
Appendix 1. Specialised Register search strategy (RCTs) Searched 04/12/04 Search updated on 17/11/2008: from January 2005 to date Search updated on 3/02/2011
E SAPPENDIC (2008)
10.1159/000057884
Safety and Efficacy of Combined High-Dose Treatment with Calcipotriol Ointment and Solution in Patients with Psoriasis
P. V. D. van de Kerkhof (2002)
10.1016/S0190-9622(98)70323-8
Calcipotriene ointment and halobetasol ointment in the long-term treatment of psoriasis: effects on the duration of improvement.
M. Lebwohl (1998)
10.1016/0190-9622(91)70069-E
A double-blind, vehicle-controlled study of clobetasol propionate 0.05% (Temovate) scalp application in the treatment of moderate to severe scalp psoriasis.
E. Olsen (1991)
10.1001/ARCHDERM.142.9.1138
1% pimecrolimus, 0.005% calcipotriol, and 0.1% betamethasone in the treatment of intertriginous psoriasis: a double-blind, randomized controlled study.
A. Kreuter (2006)
10.1016/0190-9622(95)90186-8
Calcipotriene ointment 0.005% for psoriasis: a safety and efficacy study. Calcipotriene Study Group.
A. Highton (1995)
Clobetasol propionate lotion in the treatment of moderate to severe plaque-type psoriasis.
J. Decroix (2004)
10.1126/SCIENCE.8178173
Gene for familial psoriasis susceptibility mapped to the distal end of human chromosome 17q.
J. Tomfohrde (1994)
10.1001/ARCHDERM.1996.03890260135023
Failure of topical polymyxin B to improve mild plaque psoriasis.
J. Stutz (1996)
10.1046/j.1365-2133.2002.04742.x
Quality of life in 6497 Nordic patients with psoriasis
R. Zachariae (2002)
10.1038/JID.1949.42
Additional studies on psoriasis in the tropics and in starvation camps.
R. Simons (1949)
10.1111/j.1365-2133.1989.tb01353.x
A double‐blind study of topical 1α,25‐dihydroxyvitamin D3 in psoriasis
P. Kerkhof (1989)
10.1111/j.1365-2133.1995.tb05019.x
The effect of severe psoriasis on the quality of life of 369 patients
A. Finlay (1995)
10.1016/J.JAAD.2004.05.020
Dermoscopic assessment of long-term topical therapies with potent steroids in chronic psoriasis.
F. Vazquez-Lopez (2004)
10.1016/J.CLINDERMATOL.2007.08.012
Immunopathogenesis and role of T cells in psoriasis.
K. Ghoreschi (2007)
1996a (Continued) • Known allergy to study medication
Van de Kerkhof (1996)
10.1111/j.1365-2133.2005.06972.x
Once daily vs. twice daily applications of topical treatments in psoriasis
P. Kerkhof (2005)
Evaluation of the efficacy and safety of clobetasol propionate spray in the treatment of plaque-type psoriasis.
M. Jarratt (2006)
Clobetasol propionate 0.05% spray for the management of moderate-to-severe plaque psoriasis of the scalp: results from a randomized controlled trial.
H. Sofen (2011)
10.1159/000071788
The Atrophogenic Potential and Dermal Tolerance of Calcipotriol/Betamethasone Dipropionate Ointment Compared with Betamethasone Dipropionate Ointment
J. Traulsen (2003)
Efficacy of 15% azelaic acid in psoriasis vulgaris: a randomized, controlled clinical trial.
F. Iraji (2010)
Terapia de refuerzo en pacientes con psoriasis tratada con calcipotriol
C. Ferrándiz (1998)
Short-contact treatment at home with Micanol.
G. Volden (1992)
10.1111/j.1365-2133.2007.08005.x
Folate with methotrexate: big benefit, questionable cost
I. Brownell (2007)
10.1111/j.1468-3083.2005.01331.x
Topical use of calcitriol 3 µg/g ointment in the treatment of mild‐to‐moderate psoriasis: results from an open‐label study
I. Carboni (2005)
10.1111/j.1468-3083.2006.01913.x
An investigator‐masked comparison of the efficacy and safety of twice daily applications of calcitriol 3 µg/g ointment vs. calcipotriol 50 µg/g ointment in subjects with mild to moderate chronic plaque‐type psoriasis
X. Zhu (2007)
10.1046/j.1468-3083.17.s2.1.x
The immunological basis of psoriasis
C. Griffiths (2003)
10.1111/j.1468-3083.2005.01090.x
Oral itraconazole for the treatment of seborrhoeic dermatitis: an open, noncomparative trial
O. Kose (2005)
10.3109/09546639909056009
Comparison of tacalcitol ointment with short-contact dithranol therapy in the treatment of psoriasis vulgaris: a randomized multicentre, open prospective study on efficacy and safety
Beatrix Farkas (1999)
10.1093/HMG/7.10.1537
The genetics of psoriasis: a complex disorder of the skin and immune system.
J. Bhalerao (1998)
10.1007/s001050050743
Mometason und Calcipotriol optimieren den therapeutischen Initialeffekt von Dithranol auf die chronisch stationäre Psoriasis (CSP)
P. Sander (1998)
10.1001/ARCHDERM.134.1.57
The safety and efficacy of tazarotene gel, a topical acetylenic retinoid, in the treatment of psoriasis.
G. Krueger (1998)
10.1001/archderm.144.11.1457
Clinical assessment of patients with recalcitrant psoriasis in a randomized, observer-blind, vehicle-controlled trial using indigo naturalis.
Y. Lin (2008)
10.1111/j.1365-4362.1992.tb02696.x
JOINT COMPLAINTS IN PSORIASIS PATIENTS
M. Zanolli (1992)
10.1046/j.1365-4362.2001.01244.x
A clinical study to determine the efficacy and safety of 1% methotrexate/Azone® (MAZ) gel applied topically once daily in patients with psoriasis vulgaris
L. Sutton (2001)
10.1111/j.1365-2133.2006.07369.x
Evaluation of the atrophogenic potential of different glucocorticoids using optical coherence tomography, 20‐MHz ultrasound and profilometry; a double‐blind, placebo‐controlled trial
M. Cossmann (2006)
10.1111/j.1365-2133.2006.07675.x
A classification of psoriasis vulgaris according to phenotype
C. Griffiths (2007)
10.1111/j.1365-2133.2005.06502.x
Current severe psoriasis and the Rule of Tens
A. Finlay (2005)
10.1016/J.JAAD.2005.01.010
Adverse effects of topical glucocorticosteroids.
U. Hengge (2006)
10.1136/bmj.323.7303.42
Assessing the quality of controlled clinical trials
P. Jüni (2001)
10.1159/000091250
Short Contact Therapy with Tazarotene in Psoriasis Vulgaris
S. Veraldi (2006)
Topical therapies for psoriasis: evidence-based review.
T. Afifi (2005)
I gave a lecture for Leo Pharmaceuticals about psoriasis and atopic eczema in 2012.
Mike Cork (2012)
Germany, sponsored the trial
Fujisawa GmbH (2008)
Topical monotherapy with clobetasol propionate spray 0.05% in the COBRA trial.
A. Menter (2007)
Clobetasol propionate emollient 0.05 percent: hypothalamic-pituitary-adrenal-axis safety and four-week clinical efficacy results in plaque-type psoriasis.
J. Jorizzo (1997)
10.2340/0001555577228230
A randomized double-blind comparison of the effects on systemic calcium homeostasis of topical calcitriol (3 micrograms/g) and calcipotriol (50 micrograms/g) in the treatment of chronic plaque psoriasis vulgaris.
J. Bourke (1997)
10.1016/j.ijpharm.2010.09.007
Development, evaluation and clinical studies of Acitretin loaded nanostructured lipid carriers for topical treatment of psoriasis.
Y. Agrawal (2010)
10.3109/09546639509080590
Clinical evaluation of a PAF-antagonist in psoriasis vulgaris
H. Wolska (1995)
Clinical trial of a potent non-halogenated topical steroid, Budesonide.
G. Agrup (1981)
10.1186/1477-7525-2-12
Validation of a general measure of treatment satisfaction, the Treatment Satisfaction Questionnaire for Medication (TSQM), using a national panel study of chronic disease
M. Atkinson (2004)
10.1111/J.1365-2133.2004.06134.X
The impact of a two-compound product containing calcipotriol and betamethasone dipropionate (Daivobet®/Dovobet®) on the quality of life in patients with psoriasis vulgaris: a randomized controlled trial
P. Kerkhof (2004)
10.1001/ARCHDERM.141.1.43
Topical tacrolimus ointment combined with 6% salicylic acid gel for plaque psoriasis treatment.
C. Carroll (2005)
10.1016/S0738-081X(97)00010-2
Combinations and comparisons.
P. Kerkhof (1997)
10.1001/ARCHDERM.1931.01450010455012
TREATMENT OF PSORIASIS: CONTINUED OBSERVATIONS ON THE USE OF CRUDE COAL TAR AND ULTRAVIOLET LIGHT
W. H. Goeckerman (1931)
10.1159/000098576
The Efficacy and Safety of Topically Applied Indigo Naturalis Ointment in Patients with Plaque-Type Psoriasis
Y. Lin (2007)



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