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The Cochrane Database of Systematic... Apr 2009Chronic plaque psoriasis is the most common type of psoriasis and is characterised by redness, thickness and scaling. First line management of chronic plaque psoriasis... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chronic plaque psoriasis is the most common type of psoriasis and 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 with placebo; to compare vitamin D analogues with other topical treatments.
SEARCH STRATEGY
The Cochrane Skin Group's Trials Register was searched (2004/12). To update an unpublished 2002 review we also searched CENTRAL in The Cochrane Library (Issue 1,2005); MEDLINE (to 2005/02); EMBASE (to 2005/08); Science Citation Index (to 2005); Biosis (to 2005); Dissertation Abstracts (all publication years); Inside Conferences (all publication years); SIGLE (to 2005); National Research Register (all projects with a start date of 2001 to 2005); metaRegister of Current Controlled Trials.
SELECTION CRITERIA
Randomised trials comparing treatments against placebo or against vitamin D analogues 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 triallists and companies for missing data. We extracted data on withdrawals and adverse events.
MAIN RESULTS
The review included 131 RCTs with 21,448 participants. Vitamin D was significantly more effective than placebo, although there was a wide variation in effect size with the standardised mean difference (SMD) ranging from -0.82 (95% CI -1.34 to -0.29) to -1.90 (95% CI -2.09 to -1.71). With one exception, all corticosteroids performed better than placebo, with potent corticosteroids (SMD: -0.95 (95% CI: -1.11 to -0.80; I(2): 61.1%; 17 studies; 2386 participants)) having smaller benefits than very potent corticosteroids (SMD: -1.29 (95% CI: -1.45 to -1.13; I(2): 53.2%; 11 studies; 1571 participants)). Dithranol and tazarotene performed better than placebo. Head-to-head comparisons of vitamin D against potent or very potent corticosteroids found no significant differences. However, combined treatment with vitamin D /corticosteroid performed significantly better than either vitamin D alone or corticosteroid alone. Vitamin D performed better than coal tar, but findings relative to dithranol were mixed. Potent corticosteroids were less likely than vitamin D to cause local adverse events. No comparison of topical agents found a significant difference in systemic adverse effects.
AUTHORS' CONCLUSIONS
Corticosteroids perform as well as vitamin D analogues and are associated with a lower incidence of local adverse events. Further research is required to inform long-term maintenance treatment.
Topics: Administration, Topical; Adrenal Cortex Hormones; Bone Density Conservation Agents; Chronic Disease; Humans; Psoriasis; Randomized Controlled Trials as Topic; Vitamin D
PubMed: 19370616
DOI: 10.1002/14651858.CD005028.pub2 -
The Journal of Dermatological Treatment Aug 2017To review published literature describing the global use of topical antipsoriatics. (Review)
Review
OBJECTIVE
To review published literature describing the global use of topical antipsoriatics.
MATERIALS AND METHODS
Search for English-language articles in Embase, Pubmed, PsycINFO and Cochrane Library.
RESULTS
Fifty-four selected publications were found, describing psoriasis patients' use of topical antipsoriatics, using six different methods to collect data. The eight most frequently used topical treatments from the regions North/South America, North/Central/South Europe, Asia, Middle East and Australia were: corticosteroids used by 16-79%, complementary and alternative medicines used by 10-62%, phototherapies used by 0.4-75%, calcipotriol used by 4.2-73%, corticosteroid/calcipotriol combinations used by 3.3-71%, tar used by 0.8-66%, anthralin used by 15% and emollients used as monotherapy by 1-23%. Rates of patient-reported adherence to topical remedies ranged from 51% to 90% and rates of patient-reported satisfaction with topical as it pertains to symptom control ranged from 12% to 52%.
CONCLUSION
The identified use patterns are varying and reflect a lack of data from large parts of the world and noncomparable studies using heterogeneous study designs. However, this study emphasizes the importance of medical professionals involvement of the patient with respect to choosing prescribed topical treatment and the possibility of patients' use of alternative treatments. More drug utilization studies, both survey and register based, from different parts of the world are needed to provide more conclusive evidence about patients' use of topical antipsoriatics.
Topics: Administration, Topical; Adrenal Cortex Hormones; Anthralin; Calcitriol; Dermatologic Agents; Drug Therapy, Combination; Humans; Patient Compliance; Psoriasis
PubMed: 27786594
DOI: 10.1080/09546634.2016.1254331 -
The Cochrane Database of Systematic... Mar 2013Chronic plaque psoriasis is the most common type of psoriasis, and it is characterised by redness, thickness, and scaling. First-line management of chronic plaque... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Administration, Topical; Adrenal Cortex Hormones; Bone Density Conservation Agents; Chronic Disease; Facial Dermatoses; Humans; Psoriasis; Randomized Controlled Trials as Topic; Scalp Dermatoses; Vitamin D
PubMed: 23543539
DOI: 10.1002/14651858.CD005028.pub3 -
Journal of the American Academy of... Nov 2013Chronic plaque psoriasis is the most common type of psoriasis and is characterized by redness, thickness, and scaling. First-line management is with topical treatments. (Review)
Review
BACKGROUND
Chronic plaque psoriasis is the most common type of psoriasis and is characterized by redness, thickness, and scaling. First-line management is with topical treatments.
OBJECTIVE
We sought to undertake a Cochrane review of topical treatments for chronic plaque psoriasis.
METHODS
We systematically searched major databases for randomized controlled trials. Trials reported improvement using a range of related measures; standardized, pooled findings were translated onto a 6-point improvement scale.
RESULTS
The review included 177 randomized controlled trials with 34,808 participants, including 26 trials of scalp psoriasis and 6 trials of inverse and/or facial psoriasis. Typical trial duration was 3 to 8 weeks. When compared with placebo (emollient base), the average improvement for vitamin-D analogues and potent corticosteroids was approximately 1 point, dithranol 1.2 points, very potent corticosteroids 1.8 points, and combined vitamin-D analogue plus steroid 1.4 points once daily and 2.2 points twice daily. However, these are indicative benefits drawn from heterogeneous trial findings. Corticosteroids were more effective than vitamin D for treating psoriasis of the scalp. For both body and scalp psoriasis, potent corticosteroids were less likely than vitamin D to cause skin irritation.
LIMITATIONS
Reporting of benefits, adverse effects, and safety assessment methods was often inadequate. In many comparisons, heterogeneity made the size of treatment benefit uncertain.
CONCLUSIONS
Corticosteroids are as effective as vitamin-D analogues and cause less skin irritation. However, further research is needed to inform long-term maintenance treatment and provide appropriate safety data.
Topics: Administration, Topical; Adrenal Cortex Hormones; Chronic Disease; Humans; Psoriasis; Randomized Controlled Trials as Topic; Vitamin D
PubMed: 24124809
DOI: 10.1016/j.jaad.2013.06.027 -
Dermatology Online Journal Feb 2003Mild to moderate psoriasis is a disease that can often be treated with topical medications. The diversity of topical therapies and their disparate side effects... (Comparative Study)
Comparative Study Review
Mild to moderate psoriasis is a disease that can often be treated with topical medications. The diversity of topical therapies and their disparate side effects complicates treatment planning. Our purpose is to compare the rates of adverse events associated with different topical psoriasis treatments. A review of medical literature from 1996 to March, 2002 was conducted using guidelines set by QUORUM statement criteria. In monotherapy studies, corticosteriods caused fewer adverse reactions compared to vitamin D analogues and tazarotene. In combination studies adverse event rates were higher than in monotherapy studies, except for the combination of topical steroid and calcipotriene which decreased irritation. Irritant contact dermatitis was the main side effect with vitamin D analogues, tazarotene, dithranol or coal tar, while side effects of topical corticosteriods included headache, viral infection and skin atrophy. Topical agents for psoriasis are usually well-tolerated without severe side effects. Formulating a patient's medication regimen should take into account the needs for short-term management and long-term control of psoriasis. Since clearance is not a realistic expectation, reasonable goals should be set as excessive use of topical treatments may increase the risk of both cutaneous and systemic side effects.
Topics: Administration, Topical; Adrenal Cortex Hormones; Anthralin; Calcitriol; Coal Tar; Dermatologic Agents; Dihydroxycholecalciferols; Drug Therapy, Combination; Erythema; Humans; Nicotinic Acids; Pain; Pruritus; Psoriasis; Vitamin D
PubMed: 12639460
DOI: No ID Found -
The British Journal of Dermatology Mar 2002There is clinical uncertainty about the appropriate use of first-line topical treatments for psoriasis. (Review)
Review
BACKGROUND
There is clinical uncertainty about the appropriate use of first-line topical treatments for psoriasis.
OBJECTIVES
To assess the relative effectiveness and tolerability of topical treatments for psoriasis suitable for use both in primary and secondary care.
METHODS
All major medical databases of published literature were searched electronically; references of trial reports and recent reviews were searched; authors and companies were contacted for missing data from published reports. The study selection comprised: (1) randomized placebo-controlled trials of topical treatments for psoriasis; and (2) randomized head-to-head studies of the new vitamin D3 derivative treatments for psoriasis that reported clinical outcome using a Total Severity Score (TSS), Psoriasis Area Severity Index or Investigator Assessment of Global Improvement. Eligibility and validity were assessed and data extracted independently by two authors. Clinical outcomes were pooled using a random effect standardized weighted mean difference (SWMD) metric, including 3380 patients randomized in 41 placebo (vehicle)-controlled trials and 4898 patients randomized in 28 head-to-head studies.
RESULTS
There was a significant benefit in favour of active treatments against vehicle, SWMD: -1.06 (95% confidence interval [CI]: -1.26 to -0.86), approximately a 2-point improvement on a 12-point TSS after 6-8 weeks of treatment. The only significantly different benefit was for very potent corticosteroids: SWMD: -1.51 (95% CI: -1.76 to -1.25), approximately a 3-point improvement on a 12-point TSS. Head-to-head studies support these findings, except that calcipotriol was estimated to be more effective than dithranol, coal tar and other vitamin D3 derivatives. Polytherapy, using a potent steroid and calcipotriol, was more effective than calcipotriol alone: SWMD 0.42 (95% CI: 0.12-0.72 ) approximately a 0.8-point improvement on a 12-point TSS. No important differences in withdrawal or reporting of adverse events were identified.
CONCLUSIONS
Trials of short duration neither adequately inform the management of chronic disease nor describe the sequelae of treatment. The evidence base for long-term care, reflecting the disease pathway, should be improved. Combination therapy with topical vitamin D analogues and steroids, and maintenance therapy following treatment response merit further investigation.
Topics: Administration, Cutaneous; Administration, Topical; Anti-Inflammatory Agents; Calcitriol; Drug Therapy, Combination; Glucocorticoids; Humans; Primary Health Care; Psoriasis; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 11952534
DOI: 10.1046/j.1365-2133.2000.04713.x -
Journal of the American Academy of... Mar 2018
Review
Topics: 11-beta-Hydroxysteroid Dehydrogenases; Alopecia Areata; Anthralin; Bimatoprost; Cyclopropanes; Dermatologic Agents; Drug Therapy, Combination; Eyebrows; Eyelashes; Facial Dermatoses; Humans; Latanoprost; Minoxidil; Photosensitizing Agents; Prostaglandins F, Synthetic
PubMed: 28987491
DOI: 10.1016/j.jaad.2017.09.054 -
Archives of Dermatology Jul 1999In a cost-effectiveness study currently being conducted of short-contact anthralin treatment for psoriasis in an outpatient setting as compared with the standard... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In a cost-effectiveness study currently being conducted of short-contact anthralin treatment for psoriasis in an outpatient setting as compared with the standard treatment with UV-B radiation, the excess incidence (IDD) of skin cancer due to exposure to UV-B could not be ascertained because the study did not last long enough. A meta-analysis of published data was deemed appropriate.
OBJECTIVE
To quantify the IDD of nonmelanoma skin cancer as a function of the total dose of UV-B and specific for time since first exposure, age at first treatment, and other treatments received.
METHODS
Systematic review of the literature with meta-analysis of all available evidence published in English, French, German, or Dutch between 1980 and 1996.
RESULTS
Four articles contained information that enabled us to calculate an overall IDD of nonmelanoma skin cancer. The estimates varied between -0.6 and 2 extra skin cancers per 100 patients with psoriasis treated with UV-B phototherapy per year. However, these estimates were calculated under several assumptions, and do not allow for the construction of a dose-response model specific for time since exposure or age at first treatment. A model based on animal data suggests that a total of 5 excess skin cancers can be expected per 100 treated in the 60 years after the start of treatment with 500 minimum effective doses of UV-B per year from age 25 years.
CONCLUSIONS
The available evidence is insufficient for quantifying the IDD of nonmelanoma skin cancer in patients with psoriasis treated with UV-B radiation. However, it seems unlikely that the excess risk exceeds 2% per year. As yet, it is not possible to assess at what level of exposure this IDD occurs, or how long after exposure excess risk is present.
Topics: Humans; Neoplasms, Radiation-Induced; Psoriasis; Skin Neoplasms; Ultraviolet Therapy
PubMed: 10411159
DOI: 10.1001/archderm.135.7.834 -
Journal of the European Academy of... Apr 2013Despite the availability of newer topical treatments, classical topical treatments for chronic plaque psoriasis still have an important position for selected patient... (Review)
Review
BACKGROUND
Despite the availability of newer topical treatments, classical topical treatments for chronic plaque psoriasis still have an important position for selected patient populations. The vast majority of patients are treated with a combination of topicals. The question arises: what is the evidence behind these approaches?
OBJECTIVES
To systematically review all available literature on efficacy and safety of combinations of classical topical treatments in chronic plaque psoriasis, including all combinations with dithranol, coal tar and penetration enhancers, and ultimately, to propose recommendations for combination treatment.
METHODS
Standardized literature searches in PubMed, EMBASE and the Cochrane Controlled Clinical Trial Register, and allocation of the degree of evidence was carried out.
RESULTS
In total 2918 publications on topical combination therapy were revealed, of which 48 articles on combinations of classical treatments. In this article, the results concerning the 19 included publications are stated. The majority of combination regimens is at least as effective as monotherapies, and is generally well tolerated.
CONCLUSIONS
Methods of classical treatments are not standardized and different protocols in different treatment settings are used. Therefore the interpretation of study results cannot be generalized. Most evidence was found to recommend the use of a combination regimen of topical corticosteroids and salicylic acid, above monotherapy with either component. Also, the combinations of dithranol with superpotent corticosteroids or with coal tar may be preferred above both monotherapies. In case first-line treatments and systemic therapies are not effective or contraindicated, combinations of classical topicals may provide an important opportunity.
Topics: Administration, Topical; Dermatologic Agents; Drug Therapy, Combination; Humans; Psoriasis
PubMed: 22779910
DOI: 10.1111/j.1468-3083.2012.04640.x