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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 -
Journal of the American Academy of... Jun 2010Evidence-based recommendations for therapeutic decision making in childhood psoriasis are lacking. (Review)
Review
BACKGROUND
Evidence-based recommendations for therapeutic decision making in childhood psoriasis are lacking.
OBJECTIVES
We sought to systematically review all available literature concerning treatment efficacy and safety in childhood psoriasis and to propose a recommendation for topical and systemic treatment of childhood psoriasis.
METHODS
Databases searched were PubMed, EMBASE, and the Cochrane Controlled Clinical Trial Register. All studies reporting on efficacy and safety of all treatment options in childhood psoriasis were obtained and a level of evidence was determined.
RESULTS
Literature search revealed 2649 studies, of which 64 studies met the inclusion criteria. The majority of topical and systemic therapies given in childhood psoriasis are efficacious. Short-term side effects were usually mild; long-term side effects were not described.
LIMITATIONS
Most conclusions formulated are not based on randomized controlled trials.
CONCLUSIONS
A rough summary of the proposed algorithm is as follows: first, calcipotriene with/without topical corticosteroids, followed by dithranol. Methotrexate is considered to be the systemic treatment of choice.
Topics: Anthralin; Anti-Bacterial Agents; Calcineurin Inhibitors; Calcitriol; Child; Dermatologic Agents; Glucocorticoids; Humans; Methotrexate; Psoriasis
PubMed: 19900732
DOI: 10.1016/j.jaad.2009.06.048 -
BMJ Clinical Evidence Jan 2009Psoriasis affects 1-3% of the population, in some people causing changes to the nails and joints in addition to skin lesions. (Review)
Review
INTRODUCTION
Psoriasis affects 1-3% of the population, in some people causing changes to the nails and joints in addition to skin lesions.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of systemic drug treatments, topical drug treatments, and non-drug treatments (other than ultraviolet light) for chronic plaque psoriasis? What are the effects of ultraviolet light treatments for chronic plaque psoriasis? What are the effects of combined treatment with drugs plus ultraviolet light on chronic plaque psoriasis? What are the effects of combined systemic plus topical drug treatments for chronic plaque psoriasis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 122 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, adding calcipotriol (topical) to psoralen plus ultraviolet light A or ultraviolet light B, adding oral retinoids to psoralen plus ultraviolet A (PUVA), alefacept, balneotherapy, ciclosporin, dithranol, T cell-targeted therapies, cytokine blocking agents, emollients (alone or plus ultraviolet light B), etanercept, fish oil supplementation, fumaric acid derivatives, Goeckerman treatment, heliotherapy, infliximab, Ingram regimen, keratolytics (salicylic acid, urea), leflunomide, methotrexate, oral pimecrolimus, phototherapy plus balneotherapy, psoralen plus ultraviolet A, psychotherapy, oral retinoids (alone or with ultraviolet light B), systemic drug treatments plus topical vitamin D derivatives, tars, tazarotene, topical corticosteroids (alone or plus oral retinoids), topical Vitamin D derivatives, ultraviolet light A, and ultraviolet light B.
Topics: Adrenal Cortex Hormones; Animals; Dermatologic Agents; Humans; Phototherapy; Psoriasis; Ultraviolet Rays; Ultraviolet Therapy
PubMed: 19445765
DOI: No ID Found -
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 Cochrane Database of Systematic... Apr 2008Alopecia areata is a disorder in which there is loss of hair causing patches of baldness but with no scarring of the affected area. It can affect the entire scalp... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Alopecia areata is a disorder in which there is loss of hair causing patches of baldness but with no scarring of the affected area. It can affect the entire scalp (alopecia totalis) or cause loss of all body hair (alopecia universalis). It is a relatively common condition affecting 0.15% of the population. Although in many cases it can be a self-limiting condition, nevertheless hair loss can often have a severe social and emotional impact.
OBJECTIVES
To assess the effects of interventions used in the management of alopecia areata, alopecia totalis and alopecia universalis.
SEARCH STRATEGY
We searched the Cochrane Skin Group Specialised Register in February 2006, the Cochrane Central Register of Controlled Clinical Trials (The Cochrane Library Issue 1, 2006), MEDLINE (from 2003 to February 2006), EMBASE (from 2005 to February 2006), PsycINFO (from 1806 to February 2006), AMED (Allied and Complementary Medicine, from 1985 to February 2006), LILACS (Latin American and Caribbean Health Science Information database, from 1982 to February 2006), and reference lists of articles. We also searched online trials registries for ongoing trials.
SELECTION CRITERIA
Randomised controlled trials that evaluated the effectiveness of both topical and systemic interventions for alopecia areata, alopecia totalis, and alopecia universalis.
DATA COLLECTION AND ANALYSIS
Two authors assessed trial quality and extracted the data. We contacted trial authors for more information. We collected adverse effects information from the included trials.
MAIN RESULTS
Seventeen trials were included with a total of 540 participants. Each trial included from 6 to 85 participants and they assessed a range of interventions that included topical and oral corticosteroids, topical ciclosporin, photodynamic therapy and topical minoxidil. Overall, none of the interventions showed significant treatment benefit in terms of hair growth when compared with placebo. We did not find any studies where the participants self-assessed their hair growth or quality of life.
AUTHORS' CONCLUSIONS
Few treatments for alopecia areata have been well evaluated in randomised trials. We found no RCTs on the use of diphencyprone, dinitrochlorobenzene, intralesional corticosteroids or dithranol although they are commonly used for the treatment of alopecia areata. Similarly although topical steroids and minoxidil are widely prescribed and appear to be safe, there is no convincing evidence that they are beneficial in the long-term. Most trials have been reported poorly and are so small that any important clinical benefits are inconclusive. There is a desperate need for large well conducted studies that evaluate long-term effects of therapies on quality of life. Considering the possibility of spontaneous remission especially for those in the early stages of the disease, the options of not being treated therapeutically or, depending on individual preference wearing a wig may be alternative ways of dealing with this condition.
Topics: Alopecia Areata; Humans; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 18425901
DOI: 10.1002/14651858.CD004413.pub2 -
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 -
BMJ (Clinical Research Ed.) Apr 2000To evaluate the comparative efficacy and tolerability of topical calcipotriol in the treatment of mild to moderate chronic plaque psoriasis. (Comparative Study)
Comparative Study Review
OBJECTIVES
To evaluate the comparative efficacy and tolerability of topical calcipotriol in the treatment of mild to moderate chronic plaque psoriasis.
DESIGN
Quantitative systematic review of randomised controlled trials.
SUBJECTS
6038 patients with plaque psoriasis reported in 37 trials.
MAIN OUTCOME MEASURES
Mean difference in percentage change in scores on psoriasis area and severity index, and response rate ratios for both patients' and investigators' overall assessments of marked improvement or better. Adverse effects were estimated with the rate ratio, rate difference, and number needed to treat.
RESULTS
Calcipotriol was at least as effective as potent topical corticosteroids, calcitriol, short contact dithranol, tacalcitol, coal tar, and combined coal tar 5%, allantoin 2%, and hydrocortisone 0.5%. Calcipotriol caused significantly more skin irritation than potent topical corticosteroids (number needed to treat to harm for irritation 10, 95% confidence interval 6 to 34). Calcipotriol monotherapy also caused more irritation than calcipotriol combined with a potent topical corticosteroid (6, 4 to 8). However, the number needed to treat for dithranol to produce lesional or perilesional irritation was 4 (3 to 5). On average, treating 23 patients with short contact dithranol led to one more patient dropping out of treatment owing to adverse effects than if they were treated with calcipotriol.
CONCLUSIONS
Calcipotriol is an effective treatment for mild to moderate chronic plaque psoriasis, more so than calcitriol, tacalcitol, coal tar, and short contact dithranol. Only potent topical corticosteroids seem to have comparable efficacy at eight weeks. Although calcipotriol caused more skin irritation than topical corticosteroids this has to be balanced against the potential long term effects of corticosteroids. Skin irritation rarely led to withdrawal of calcipotriol treatment. Longer term comparative trials of calcipotriol versus dithranol and topical corticosteroids are needed to see whether these short term benefits are mirrored by long term outcomes such as duration of remission and improvement in quality of life.
Topics: Administration, Topical; Allantoin; Anti-Inflammatory Agents; Calcitriol; Coal Tar; Dermatologic Agents; Drug Administration Schedule; Glucocorticoids; Humans; Hydrocortisone; Psoriasis
PubMed: 10753146
DOI: 10.1136/bmj.320.7240.963 -
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