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Journal of the European Academy of... Aug 2014Palmoplantar pustular psoriasis (PPPP) is a variant of psoriasis whose the association with psoriatic arthritis (PsA) has been recently described. There is limited... (Review)
Review
BACKGROUND
Palmoplantar pustular psoriasis (PPPP) is a variant of psoriasis whose the association with psoriatic arthritis (PsA) has been recently described. There is limited evidence regarding how to best reduce palmoplantar pustular psoriasis severity and to maintain remission once achieved.
OBJECTIVE
The aim of this study was to elaborate evidence-based recommendations for PPPP treatment supported by a systematic literature review.
METHODS
A systematic literature search was carried out in Embase, Medline and Cochrane Library databases from 1980 to February 2013 searching for any trial in patients with PPPP assessing therapeutic interventions not including a systemic biotherapy. The selection of articles was limited to human subjects and English or French languages.
RESULTS
Among the 675 articles identified, 29 including one Cochrane review were analysed. The Cochrane review summarised 23 randomised controlled trials (RCTs) in chronic PPPP until February 2003, including 724 patients. The authors concluded that oral retinoid therapy (acitretin), photochemotherapy or combination of both, low dose of ciclosporin or topical corticosteroids under occlusion appeared to be helpful in relieving symptoms of PPPP. Since the publication of this review, 9 open studies on PPPP treatment have been published. Three new studies evaluated the benefits of PUVA on PPPP. They all showed a better efficacy of PUVA compared to UVB therapy. One open study concluded that a retinoid treatment with an arotinoid ethylesther showed a good efficacy. Five prospective studies (level of evidence of 3) assessed Laser Excimer UVB-NB (Excimer 308 nm) in PPPP. The combined analysis of these studies showed that 64% of patients experienced an improvement of 70% at the end of treatment.
CONCLUSION
Phototherapy, ciclosporin and topical corticosteroids seem to be able to control PPPP. However, the standard of care for PPPP remains an issue and there is a strong need for reliable RCTs to better define treatment strategies for PPPP.
Topics: Acitretin; Adrenal Cortex Hormones; Cyclosporine; Dermatologic Agents; Evidence-Based Medicine; Humans; Keratolytic Agents; Photochemotherapy; Practice Guidelines as Topic; Psoriasis
PubMed: 24985558
DOI: 10.1111/jdv.12561 -
The Journal of Dermatological Treatment Jun 2015Various treatment modalities are available for cutaneous lichen planus. Pubmed, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled... (Review)
Review
Various treatment modalities are available for cutaneous lichen planus. Pubmed, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database were searched for all the systematic reviews and randomized controlled trials related to cutaneous lichen planus. Two systematic reviews and nine relevant randomized controlled trials were identified. Acitretin, griseofulvin, hydroxychloroquine and narrow band ultraviolet B are demonstrated to be effective in the treatment of cutaneous lichen planus. Sulfasalazine is effective, but has an unfavorable safety profile. KH1060, a vitamin D analogue, is not beneficial in the management of cutaneous lichen planus. Evidence from large scale randomized trials demonstrating the safety and efficacy for many other treatment modalities used to treat cutaneous lichen planus is simply not available.
Topics: Acitretin; Administration, Cutaneous; Humans; Lichen Planus
PubMed: 24916211
DOI: 10.3109/09546634.2014.933167 -
Pediatric Dermatology 2014There is lack of information and evidence-based studies on the treatment of pediatric pustular psoriasis. Previous reports have emphasized the limitations of the... (Review)
Review
There is lack of information and evidence-based studies on the treatment of pediatric pustular psoriasis. Previous reports have emphasized the limitations of the existing data and encouraged the exploration of therapy optimization through more structured research. The objective of the current study was to perform a systematic review of systemic interventions for pediatric pustular psoriasis with an emphasis on clinical response and treatment outcomes. A systematic literature search was conducted using the PubMed and Embase databases from 1982 to 2012. Of 632 references identified, 14 met our inclusion criteria and were included in the analysis. A cohort of eight patients from the Hospital for Sick Children, Toronto, Canada, was also included. Information was limited to systemic treatments in children. Only English- and Spanish-language articles were included. Information was gathered from 24 patients, 22 of whom (92%) presented with generalized pustular psoriasis and 2 (8%) with acral distribution. The mean age at presentation was 6.3 ± 4.9 years. More than one intervention was required in 12 (50%) cases. The most common therapies used for generalized pustular psoriasis were acitretin, cyclosporine, and methotrexate. We identified that there is lack of information regarding long-term response to systemic drugs because the data were focused on treatment initiation. Treatment of pustular psoriasis in pediatrics is challenging. Although acitretin, methotrexate, and cyclosporine seem to control generalized pustular psoriasis within 3 months of therapy initiation, information on long-term follow-up is lacking. Furthermore, physicians may encounter difficulties after discontinuing or tapering medications.
Topics: Acitretin; Adolescent; Child; Child, Preschool; Cyclosporine; Female; Humans; Infant; Male; Methotrexate; Pediatrics; Psoriasis; Treatment Outcome
PubMed: 24890463
DOI: 10.1111/pde.12351 -
Journal of the American Academy of... Oct 2013The ichthyoses comprise a group of inherited disorders of keratinization. Because of the need for lifelong treatment, it is important that therapies are beneficial,... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
The ichthyoses comprise a group of inherited disorders of keratinization. Because of the need for lifelong treatment, it is important that therapies are beneficial, safe, and well tolerated.
OBJECTIVES
We sought to review the evidence on existing treatments for the congenital ichthyoses, excluding ichthyosis vulgaris.
METHOD
We undertook a systematic review using the methodology of the Cochrane Collaboration. Articles published in MEDLINE, EMBASE, and CENTRAL and registered clinical trials were screened. Randomized controlled trials involving patients with the inherited ichthyoses, either syndromic or nonsyndromic but excluding ichthyosis vulgaris, were considered.
RESULTS
Six trials met the inclusion criteria. Topical treatments including 5% urea, 20% propylene glycol alone or in combination with 5% lactic acid, calcipotriol ointment, and liarozole 5% cream showed therapeutic benefit. Oral liarozole, a retinoic acid metabolism blocking agent, showed no advantage over oral acitretin.
LIMITATIONS
Most studies were performed on a small sample of patients and lacked methodological and reporting quality. The small number of trials and the nearly constant positive results make publication bias likely. The absence of standardization of outcome measures precluded the comparison of studies.
CONCLUSIONS
Topical treatments including emollients, calcipotriol ointment, and liarozole cream seem to have therapeutic benefit and a good safety profile, although the use of topical calcipotriol is limited by a maximum weekly dose of 100 g. The advantage of oral liarozole over acitretin is uncertain. Multicenter trials comparing oral and topical interventions and evaluation of long-term outcomes are needed.
Topics: Administration, Oral; Administration, Topical; Drug Therapy, Combination; Female; Humans; Ichthyosis Vulgaris; Ichthyosis, Lamellar; Keratolytic Agents; Male; Patient Satisfaction; Prognosis; Randomized Controlled Trials as Topic; Retinoids; Risk Assessment; Severity of Illness Index; Treatment Outcome
PubMed: 23870202
DOI: 10.1016/j.jaad.2013.05.017 -
The British Journal of Dermatology Feb 2013Hidradenitis suppurativa (HS) is a difficult disease to treat. Although the pathogenesis of this inflammatory skin disease is largely unknown, the important role of the... (Review)
Review
Hidradenitis suppurativa (HS) is a difficult disease to treat. Although the pathogenesis of this inflammatory skin disease is largely unknown, the important role of the immune system has been demonstrated in both experimental and clinical studies. Clinicians are therefore increasingly prescribing systemic treatments with immunosuppressive agents, but the more traditionally used systemic retinoids, especially isotretinoin, also remain relatively common therapies. In order to provide an overview of all currently available systemic immunosuppressive agents and retinoids for the treatment of HS, a systematic search was performed using the Medline and Embase databases. All published papers concerning systemic retinoids or immunosuppressive treatments for HS in adults were included. The primary endpoints were the percentages of significant responders, moderate responders and nonresponders. Other endpoints were the relapse rate and adverse events. In total 87 papers were included, comprising 518 patients with HS who were treated with systemic retinoids, biological agents or another immunosuppressive agents, including colchicine, ciclosporin, dapsone or methotrexate. The highest response rates were observed with infliximab, adalimumab and acitretin. Overall, the quality of evidence was low and differed between the agents, making direct comparisons difficult. However, based on the amount of evidence, infliximab and adalimumab were the most effective agents. Acitretin was also effective in HS, although the quality of the evidence was low. The therapeutic effect of isotretinoin is questionable. Randomized controlled trials are needed to confirm the effectiveness of acitretin, and to identify the most effective immunosuppressive agents in HS.
Topics: Adult; Aged; Biological Products; Dermatologic Agents; Evidence-Based Medicine; Hidradenitis Suppurativa; Humans; Immunosuppressive Agents; Middle Aged; Retinoids; Treatment Outcome; Young Adult
PubMed: 23106519
DOI: 10.1111/bjd.12104 -
The Cochrane Database of Systematic... Sep 2012Mycosis fungoides is the most common type of cutaneous T-cell lymphoma, a malignant, chronic disease initially affecting the skin. Several therapies are available, which... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Mycosis fungoides is the most common type of cutaneous T-cell lymphoma, a malignant, chronic disease initially affecting the skin. Several therapies are available, which may induce clinical remission for a time.
OBJECTIVES
To assess the effects of interventions for mycosis fungoides in all stages of the disease.
SEARCH METHODS
We searched the following databases up to January 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2010), and LILACS (from 1982). We also checked reference lists of included studies for further references to relevant RCTs. We searched online trials registries for further references to unpublished trials and undertook a separate search for adverse effects of interventions for mycosis fungoides in non-RCTs in MEDLINE in May 2011.
SELECTION CRITERIA
Randomised controlled trials (RCTs) of interventions for mycosis fungoides in people with any stage of the disease. At least 90% of participants in the trials must have been diagnosed with mycosis fungoides (Alibert-Bazin-type).
DATA COLLECTION AND ANALYSIS
Two authors independently assessed eligibility and methodological quality for each study and carried out data extraction. We resolved any disagreement by discussion. Primary outcomes were the impact on quality of life and the safety of interventions. When available, we reported on our secondary outcomes, which were the improvement or clearance of skin lesions, disease-free intervals, survival rates, relapse rates, and rare adverse effects. When possible, we combined homogeneous studies for meta-analysis. We used The Cochrane Collaboration's 'Risk of bias' tool to assess the internal validity of all included studies in six different domains.
MAIN RESULTS
The review included 14 RCTs involving 675 participants, covering a wide range of interventions. Eleven of the included trials assessed participants in clinical stages IA to IIB only (please see Table 1 for definitions of these stages).Internal validity was considerably low in studies with a high or unclear risk of bias. The main reasons for this were low methodological quality or missing data, even after we contacted the study authors, and a mean dropout rate of 26% (0% to 72%). Study size was generally small with a minimum of 4 and a maximum of 103 participants. Only one study provided a long enough follow-up for reliable survival analysis.Included studies assessed topical treatments, such as imiquimod, peldesine, hypericin, nitrogen mustard, as well as intralesional injections of interferon-α (IFN-α). The light therapies investigated included psoralen plus ultraviolet A light (PUVA), extracorporeal photopheresis (photochemotherapy), and visible light. Oral treatments included acitretin, bexarotene, and methotrexate. Treatment with parenteral systemic agents consisted of denileukin diftitox; a combination of chemotherapy and electron beam radiation; and intramuscular injections of active transfer factor. Nine studies evaluated therapies by using an active comparator; five were placebo-controlled RCTs.Twelve studies reported on common adverse effects, while only two assessed quality of life. None of these studies compared the health-related quality of life of participants undergoing different treatments. Most of the reported adverse effects were attributed to the interventions. Systemic treatments, and here in particular a combined therapeutic regimen of chemotherapy and electron beam, bexarotene, or denileukin diftitox, showed more adverse effects than topical or skin-directed treatments.In the included studies, clearance rates ranged from 0% to 83%, and improvement ranged from 0% to 88%. The meta-analysis combining the results of 2 trials comparing the effect of IFN-α and PUVA versus PUVA alone showed no significant difference in the relative risk of clearance: 1.07 (95% confidence interval 0.87 to 1.31). None of the included studies demonstrated a significant increase in disease-free intervals, relapse, or overall survival.
AUTHORS' CONCLUSIONS
This review identified trial evidence for a range of different topical and systemic interventions for mycosis fungoides. Because of substantial heterogeneity in design, small sample sizes, and low methodological quality, the comparative safety and efficacy of these interventions cannot be established on the basis of the included RCTs. Taking into account the possible serious adverse effects and the limited availability of efficacy data, topical and skin-directed treatments are recommended first, especially in the early stages of disease. More aggressive therapeutic regimens may show improvement or clearance of lesions, but they also result in more adverse effects; therefore, they are to be considered with caution. Larger studies with comparable, clearly-defined end points for all stages of mycosis fungoides, and a focus on safety, quality of life, and duration of remission as part of the outcome measures, are necessary.
Topics: Antineoplastic Agents; Humans; Mycosis Fungoides; Neoplasm Staging; Photochemotherapy; Photopheresis; Randomized Controlled Trials as Topic; Skin Neoplasms
PubMed: 22972128
DOI: 10.1002/14651858.CD008946.pub2 -
Clinical and Experimental Dermatology Aug 2011This review summarizes key clinical findings from 5 guidelines and 21 systematic reviews on psoriasis published or indexed in the period November 2009 to October 2010.... (Review)
Review
This review summarizes key clinical findings from 5 guidelines and 21 systematic reviews on psoriasis published or indexed in the period November 2009 to October 2010. The highlights include the British Association of Dermatologists guidelines on the use of biological interventions in psoriasis, and guidelines on the efficacy and use of acitretin. Biological therapies were reviewed for use in specific patient groups (such as those with hepatitis C) and from a health-economics perspective. Another systematic review focused on outcome measures used to assess the severity of psoriasis. Finally, comorbidities including cardiovascular risk were the topic of four systematic reviews.
Topics: Acitretin; Anti-Inflammatory Agents; Biological Therapy; Humans; Keratolytic Agents; Practice Guidelines as Topic; Psoriasis; Severity of Illness Index
PubMed: 21718345
DOI: 10.1111/j.1365-2230.2011.04108.x -
Journal of the European Academy of... May 2011There is limited evidence regarding the efficacy and safety of retinoids in different psoriasis subtypes. (Review)
Review
BACKGROUND
There is limited evidence regarding the efficacy and safety of retinoids in different psoriasis subtypes.
OBJECTIVE
To systematically review the available literature on: (i) modalities of administration and prescription of oral retinoids as single agent or combined therapy for the treatment of plaque-type psoriasis (PV), nail psoriasis and localized and generalized pustular psoriasis : initial and optimal dosage; (ii) skeletal toxicity of retinoid for the treatment of psoriasis.
METHODS
A systematic literature search was carried out in MEDLINE, EMBASE, and Cochrane Library databases from 1975 to 2010 searching for randomized controlled trials and observational studies evaluating 1) various dosages of retinoid in psoriasis and 2) skeletal toxicity of retinoid in psoriasis. Articles were limited to human subjects and English/French languages.
RESULTS
Efficacy of retinoids in psoriasis. Among 1348 identified references, 44 published studies were included. Starting daily dosages between 10 and 25 mg and stepwise escalation were associated with higher clinical efficacy and lower incidence of adverse events in comparison with higher doses and regimens rapidly reaching optimal dose. Retinoids as single agent therapy appeared to show limited efficacy in PV, while the good clinical efficacy reported in pustular forms should be cautiously considered, given the spontaneously remitting course of the disease. Combining retinoids with phototherapy appeared to be highly effective in patients with PV. Potential skeletal toxicity of retinoids. 15 published studies out of 105 identified references were included. There is no strong evidence of an increased risk of skeletal abnormalities in psoriasis patients treated with retinoids.
CONCLUSION
Acitretin appears to provide better efficacy in pustular psoriasis than in PV as a single agent treatment. There is no evidence for skeletal toxicity of retinoids in the setting of psoriasis, and accordingly monitoring this risk through X-ray is not warranted.
Topics: Administration, Oral; Bone Diseases; Dose-Response Relationship, Drug; Humans; Psoriasis; Retinoids; Risk Factors; Treatment Outcome
PubMed: 21388456
DOI: 10.1111/j.1468-3083.2011.03993.x -
Journal of the European Academy of... May 2011There is a high level of heterogeneity regarding the practical use of conventional systemic treatment in psoriasis. (Review)
Review
BACKGROUND
There is a high level of heterogeneity regarding the practical use of conventional systemic treatment in psoriasis.
OBJECTIVES
The aim of this study was to develop evidence-based recommendations for the use of traditional systemic treatments in psoriasis in daily clinical practice: methotrexate (MTX), cyclosporin and retinoids.
METHODS
A scientific committee selected clinically relevant questions concerning the use of MTX, cyclosporin and retinoids in psoriasis. This selection was made using the Delphi method. A systematic literature search was performed in Medline, Embase and the Cochrane Library. The articles selected for analysis were reviewed and the level of evidence was appraised according to the Oxford Levels of Evidence. An Expert consensus meeting took place in June 2010, including 66 dermatologists. Recommendations for daily use of psoriasis systemic treatments were made during interactive workshops where the evidence was reviewed. Agreement among participants and the impact of the recommendations on clinical practice were systematically assessed using voting procedure in a plenary session.
RESULTS
A total of 2800 references were identified, among which 122 articles were included in the systematic reviews. Three key recommendations on the use of MTX in psoriasis were formulated, including optimal dosage and route, use of folic acid, risk factors for liver fibrosis and monitoring of hepatotoxicity. The recommendations for cyclosporin in psoriasis focused on the modalities of cyclosporin prescription: dosage, scheme of treatment, optimal duration of treatment, renal toxicity monitoring and evidence for use of cyclosporin in non-plaque psoriasis (erythrodermic, pustular and ungueal). Recommendations were also made concerning the efficacy and safety of retinoids (mainly acitretin) in plaque and non-plaque psoriasis.
CONCLUSIONS
These recommendations for the use of traditional systemic therapies in psoriasis are evidence based and supported by a panel of dermatologists. The next step will be to disseminate these recommendations and assess the agreement of physicians who were not involved in generating the recommendations.
Topics: Cyclosporine; Dermatology; Evidence-Based Practice; Humans; Methotrexate; Psoriasis; Retinoids; Treatment Outcome
PubMed: 21388453
DOI: 10.1111/j.1468-3083.2011.03990.x -
Annales de Dermatologie Et de... Jan 2010Phototherapy, PUVA therapy and narrow-band UVB are recognised forms of first-line therapy for extensive and severe plaque psoriasis. Based on a systematic review of the... (Review)
Review
BACKGROUND
Phototherapy, PUVA therapy and narrow-band UVB are recognised forms of first-line therapy for extensive and severe plaque psoriasis. Based on a systematic review of the medical literature, we propose a good practice guideline for the use of narrow-band UVB phototherapy in this indication.
METHODS
We carried out a review of the literature published over the 20 years (1998 to 2009) in the online PubMed database. Our conclusions are based on the results of control studies or where these are absent, on a synthesis of the recommendations common practice approved by the experts of the French Society of Photodermatology. The levels of scientific proof given are based on the criteria defined by Sackett. RESULTS RECOMMENDATIONS: (1) Practical aspects. Irradiation cabins equipped with Philips TL01 tubes, either for monotherapy (42 tubes) or for combined therapy (21 UVB tubes and 21 UVA tubes), were to be certified (CE marking, ISO-DIN certification) and equipped with an accurate dosimetry system. Several valid and usable protocols exist. The indication was based on the severity and extent of the episode of psoriasis, the psychological consequences of the dermatosis, comparison of the benefit/risk ratios of the various available treatments, the ability of the patient to attend sessions (a vital factor in therapeutic compliance), the cumulative doses of UV from previous courses of treatment, and absence of contraindications, including the use of photosensitising medication. Informed consent was to be obtained from patients, who were given a validated information sheet (available at www.sfdermato.org). The study results and the value of maintenance therapy were not confirmed. (2) Adverse effects. The immediate adverse effects were generally of little consequence, with later effects alone posing problems. Because of the risk of induction of cataract, ocular protection must be used during sessions. In the absence of symptoms or known ocular disorder, prior ophthalmologic control is not considered necessary. The risk of skin cancer remains poorly defined, and this risk has not been clearly shown to be lower than with broad-spectrum UVB therapy or PUVA. The studies give no indication of the number of sessions after which therapy must be completely discontinued. In the absence of clear evaluation of oncogenic risk, it seems reasonable to set the maximum number of sessions of UVB TL01 phototherapy at 250 as with PUVA, and to include in this limit the total of all PUVA and TL01 phototherapy sessions for patients receiving both types of phototherapy (level of proof: B). In the absence of lesions requiring treatment in these areas, the face and male genital organs should be protected during treatment sessions. There is no currently available data concerning carcinogenic risk induced by TL01 in patients also on cyclosporine, methotrexate or biotherapies. In order to reduce risk and maintain patients' capacity to undergo further phototherapy sessions, we suggest (level of proof: A) the following measures: strict patient selection, use of combined synergistic therapies, annual examination of the skin and appendages of subjects receiving more than 150 phototherapy sessions, and the creation of nationally accessible patient phototherapy files. (3) Combined treatments. The purpose of such treatment is twofold: to reduce the risk of adverse effects while increasing the efficacy of TL01 phototherapy. Lesions should be sloughed before the start of phototherapy. Synergistic effects have been demonstrated for dermal corticosteroids and tazarotene, but such effects are less noticeable with topical vitamin D3 derivatives. If there are no contraindications to its prescription, we feel that acitretine has demonstrated efficacy in enhancing the effect of TL01 phototherapy. (4) Efficacy. Narrow-spectrum UVB phototherapy is considered highly effective in extensive psoriasis. At a rate of three sessions per week, it results in complete (or almost complete) eradication of lesions in 60 to 90 % of patients within 20 to 40 sessions (level of proof: A). However, the efficacy of this therapy varies according to plaque size and noticeably better results are obtained in guttate and nummular psoriasis than in psoriasis involving large plaques.
CONCLUSION
Narrow-spectrum UVB phototherapy offers a good alternative to PUVA therapy since concomitant psoralen is not required, but there are few immediate adverse effects, there is less risk of drug-induced photosensitisation, and there is no need for skin or ocular photoprotection after sessions. We recommend this approach as the first-line phototherapy (level of proof: A) in children and adolescents, and in adults with extensive moderate psoriasis involving small superficial plaques. It may also be used in pregnant or breastfeeding women and in patients with renal or hepatic insufficiency. In addition, it is preferable for HIV-positive subjects (level of proof: C). However, PUVA therapy is preferable as first-line treatment in extensive severe psoriasis involving large thick plaques (level of proof: A) and in adults of phototypes IV to VI (level of proof: B); it should also be contemplated for psoriasis refractory to UVB TL01 (level of proof: B).
Topics: Adolescent; Adult; Cataract; Child; Combined Modality Therapy; Dermatologic Agents; Eye Protective Devices; Female; Humans; Male; Neoplasms, Radiation-Induced; PUVA Therapy; Pregnancy; Pregnancy Complications; Psoriasis; Radiotherapy Dosage; Risk; Skin Neoplasms; Ultraviolet Therapy
PubMed: 20110064
DOI: 10.1016/j.annder.2009.12.004