Efficacy and safety of calcipotriol (MC 903) ointment in psoriasis vulgaris. A randomized, double-blind, right/left comparative, vehicle-controlled study

BACKGROUND

The biologically active form of vitamin D3, calcitriol, may offer a new therapeutic approach to psoriasis. Calcipotriol, a new vitamin D3 analogue, is at least 100 times less calcemic than calcitriol.

OBJECTIVE

Our purpose was to study the efficacy and safety of calcipotriol in the treatment of psoriasis vulgaris.

METHODS

In a right/left comparative, double-blind study, treatment with calcipotriol ointment (50 micrograms/gm) twice daily and placebo was given for 4 weeks. The preferred treatment was continued, without opening the code, for another 4 weeks. Efficacy, as measured by the Psoriasis Area and Severity Index and by the investigator's and patient's global assessment, and safety were assessed every 2 weeks.

RESULTS

The mean Psoriasis Area and Severity Index fell in 4 weeks from 14.2 to 6.3 with calcipotriol and from 14.1 to 9.2 with placebo (p < 0.001; 95% confidence interval for difference: 1.78-->3.94). Local side effects were equally common with calcipotriol and placebo. The mean serum calcium remained unchanged.

CONCLUSION

Topical application of up to 50 gm of calcipotriol ointment per week was found to be an effective and safe treatment of psoriasis vulgaris.

[Phlebothrombosis revealing Behçet's disease in a 13-year-old adolescent]

BACKGROUND

Behçet's disease is rare in children and is exceptionally revealed by thrombophlebitis at this age of life.

CASE REPORT

A girl, aged 13 years, was admitted after having suffered from thrombophlebitis of the right leg for 6 weeks. Her medical history included frequent attacks of aphthous stomatitis and conjunctivitis and one episode of iritis. At admission, thrombophlebitis with venous thrombosis was confirmed by Doppler; it was associated with aphthous gingivitis and two similar erosive lesions in the genital area. Technetium 99 perfusion scintiphotography revealed a right pulmonary embolism. The erythrocyte sedimentation rate was elevated but there was no change in coagulation factors or immunologic abnormalities, except for the presence of immune complexes and increased complement C3 component. Biopsy of the skin lesions showed vascularitis. There was no involvement of the eyes. The condition progressively improved with anticoagulant treatment for 1 year, followed by low doses of acetylsalicylic acid.

CONCLUSION

Phlebothrombosis, a classic complication of Behçet's disease in adults, revealed the disease in this girl. Its mechanism remains unclear and duration of anticoagulant treatment is still debated.

Cutaneous interstitial fluid protein concentrations in the inflammatory syndrome: pharmacological consequences

Concentrations of alpha 1 acid glycoprotein, albumin, transferrin, haptoglobin, immunoglobulins G, A, M and apolipoprotein B were measured in serum and suction blister fluid from a group of individuals presenting a biologically proven inflammatory syndrome, and from a control group. Protein values in suction blister fluid did not change from the 2nd to the 3rd h after the beginning of blister formation. The ratio of the concentration of proteins in blister fluid and serum did not differ significantly between the groups. However, a 25% decrease in blister fluid albumin and a 100% increase in blister fluid alpha 1 acid glycoprotein, recorded in the inflammatory group, were worth noting, since they possibly influence the tissular distribution of some protein-binding drugs. Finally, an inverse relationship was established between the blister fluid/serum concentration ratio and the respective molar mass of each protein.

Eczematous dermatitis in relation to carbon ligamentoplasty

Carbon biomedical devices are widely used in prosthetic surgery; their biocompatibility is excellent and cutaneous or mucosal adverse effects of carbon material remain exceptional. We describe a patient who developed an eczematous dermatitis on the right knee in the vicinity of a ligamentoplasty performed 2 months earlier. Patch testing with the carbon ligament was positive. Although the scattering of carbon material in the surrounding tissues is well known, cutaneous complications have, to our knowledge, never been reported.

Hereditary epidermolytic palmoplantar keratoderma associated with breast and ovarian cancer in a large kindred

We report a large kindred in which palmoplantar keratoderma occurred in association with breast or ovarian cancer or both. This kindred consisted of 61 members of four generations. Thirty-five individuals had palmoplantar keratoderma, including eight women who also had breast or ovarian cancer or both. Five of the six women with breast cancer and both the women with ovarian cancer have died. The proband presented with a yellowish, uniform hyperkeratosis surrounded by a red border covering the entire surface of the palms and soles. Light microscopic examination showed features of epidermolytic hyperkeratosis, and ultrastructural examination revealed the typical markers for this entity, cytolysis and clumps of keratin filaments. This kindred is the first, to our knowledge, to have an association of epidermolytic hyperkeratosis and internal malignancy.

A chronic, infantile, neurological, cutaneous and articular (CINCA) syndrome. A specific entity analysed in 30 patients

We have studied the clinical presentation and course of a chronic inflammatory disease occurring in childhood and observed in 30 patients. The first symptoms were generally present at birth, except in a few patients where they were first noticed in early infancy. All the patients had the association of three main symptoms: neurological, cutaneous and articular. The skin rash was the first symptom observed in all the patients and looked like a chronic non pruritic urticaria varying during the day. The articular manifestations involved knees, ankles and feet, elbows, wrists and hands unaffecting the other joints. They could be mild giving arthritis during flare-ups or severe with major radiological modifications affecting the epiphysis, metaphysis and growth cartilage. The neurological manifestations were characterized by a chronic meningitis and symptoms indicating meningeal irritation: headaches, seizures, spasticity of legs. Most patients had a cerebral atrophy and a low IQ. Sensory organ involvement occurred progressively during the follow-up: ocular inflammation with optic atrophy, deafness and hoarseness. Common morphological features characterized these patients with short stature, head enlargement, saddle back nose and short and thick extremities with clubbing of fingers. The course was that of a chronic inflammatory disease with numerous flare-ups associating fever, splenomegaly and adenomegaly. Except for a high level of eosinophils in blood, CSF and tissues, the biology was non specific and only exhibited features of inflammation. Except for two families, the disease was sporadic. A high frequency of prematurity with features resembling a foetal infection was observed but no proof of a possible causal virus has so far been found so that etiology remains unknown.

Multiple glomus tumors associated with multiple neoplasias

We report the case of a 60-year-old man who presented with a lentigo maligna melanoma, which led to the discovery of a malignant endobronchial tumor and who had noticed the appearance of disseminated multiple glomus tumors about 10 years before. The late onset of this form of benign vascular tumor raises the question whether multiple glomus tumors may have been, in this case, a cutaneous marker of the development of underlying malignancy.

[A new case of Menkes syndrome. Prenatal exclusion diagnosis in a subsequent pregnancy]

Authors report the cases of a boy with a Menkes' disease which began by a convulsive encephalopathy at the age of two months with growth failure and metaphysical abnormalities. An oldest brother died at 2 years of age in an analogous scene. The diagnosis proved to be founded by the low serum copper and coeruleo-plasmia levels and by the increased uptake of copper in the cultured skin-fibroblasts. The hair was thin and kinky; microscopical study showed pili torti and trichorrhexis nodosa. For the following pregnancy of the mother, a prenatal diagnosis by precocious amniocentesis (amniotic fluid punction) allowed to say that the boy she was expecting for was clear of the disease because of the normal uptake of copper 64 Cu in cultured amniotic fluid cells of the foetus. Authors recall that Menkes' disease is a X linked recessive disorder beginning by epileptic seizure in the early months of life. The basic biochemical lesion of copper metabolism is unknown; there are abnormalities in copper and his binding protein (metallothionein) distribution with increased level is the kidney and decreased level in brain and liver. The copper therapy does not lead to clinical improvement. There is now a prenatal diagnosis: the study of copper uptake in cultured amniotic fluid cells of male fetus. It is abnormally increased in Menkes' disease.

[Anhidrotic ectodermal dysplasia (apropos of 3 families). Abnormal hair, a sign of heterozygosity?]

The authors report three cases of anidrotic ectodermal dysplasia with an X-linked form. Two cases are sporadic forms, followed up during ten years; the third case is a familial form followed-up through six generations. With their personal cases, the authors insist on the repercussions in the everyday life; they report the signs which must search for an heterozygosis among the females of this families: hypoidrosis, hypodontia, hair shaft abnormalities under polarized light, special look of the face of those females who are alike sometimes wonderfully.

[Evaluation of cardiovascular disturbances in patients with erythrodermic skin diseases by echocardiography (author's transl)]

Echocardiography was performed in seventeen patients with acute or chronic erythrodermic skin disease, to assess the cardiovascular disturbances. Fundamental difference is between the acute erythrodermic skin diseases, in which the cardiac output is low and the chronic erythrodermic skin diseases in which the cardiac output is very high, during the attacks. The reasons of this difference are studied. The ventricular function parameters are always normal and the hemodynamic disturbances seem only to be related to the modifications of the cardiac output induced by the erythrodermic skin diseases.

[Pyoderma gangrenosum and chronic myeloïd leukemia. Two new cases (author's transl)]

Two new cases of pyoderma gangrenosum with chronic myeloid leukemia are described and added to three others of the literature. Pyoderma gangrenosum is often bullous, painful and progresses quickly. It seems to have a bad prognosis in myeloid leukemia as in polycythemia vera, in which it appears lately as an evolution to myelofibrosis or acute leukemia transformation. Chemotactic disorders of polynuclear may be the main etiological factor in these cases.

[A case of temporal arteritis accompanied with appearance of "cold areas" on the liver scan (author's transl)]

The authors report a case of temporal arteritis accompanied with appearance of "cold areas" on the liver scan, regressing after steroid therapy. This observation confirms the existence of hepatic manifestation in giant cell arteritis and evokes a discussion of their mechanism. A hypothesis of hepatic ischemia is proposed.

[Cutaneous manifestations observed during prolonged intravenous feeding: 3 cases. Review of the literature (author's transl)]

3 patients (one infant and two adults) in prolonged intravenous feeding for digestive diseases developed cutaneous symptoms resembling acrodermatitis enteropathica. Essential fatty acid and hypozincemia (in 2 of 3 cases) are found. The dermatitis disappeared slowly with oral alimentation in 2 cases, and in a few days in the third one, with oral zinc sulfate. Review of literature shows that dermatitis occurring during prolonged intravenous feeding is attributed to essential fatty acid, zinc, or less often amino acid, deficiency. But resemblance of dermatitis with acrodermatitis enteropathica in most cases, high frequency of hypozincemia, and dramatic effects of treatment with zinc salts allow to think, that zinc is a key factor. Nevertheless, it is necessary to study simultaneously those different parameters and also vitamins A, E and B to conclude whether it exists or not many deficiencies (related or not) as an etiologic factor for cutaneous symptoms.

[Hyperacute periarteritis nodosa complicating Basedow's disease]

The symptoms and the evolution of necrotizing vasculitis vary greatly. The authors illustrate the case of an 18 year old patient with a history of frequent allergic manifestations (urticaria and others) who was found to have, in septembre 1975, a typical case of Grave's disease. During the following 2 months she was treated with an iodide derivative. One year later the clinical signs increased to the point where a treatment associating lugol, carbamizole and propanolol was deemed necessary. Less than 2 months later there developed a polyvisceral disease with oscillating fever, polyarthralgia and necrotizing vasculitis. The plurivisceral nature of the illness was further illustrated by the presence of a hyperreflexia, a glomerulopathy and retinal exsudats. A muscle biopsy revealed the necrotizing vasculitis with granulomas typical of periarteritis nodosa. Cardiac, neurologic and renal complications were responsable for a rapid down-hill course and despite corticoïdes and immunosuppresive drugs, the patient died after a few weeks of treatment. That periarteritis nodosa should complicate the evolution of Grave's disease suggests a connection between the two, very probably immunologic in nature. The role of drugs capable of inducing vasculitis must be explored, especially the iodide derivatives, the antithyroïd medications or their association. Such cases, even though they may be rare, should incite special care in the prescription of antithyroïd drugs in the allergic patient.

[Adult Letterer-Siwe's disease. Review of literature (author's transl)]

Letterer-Siwe syndrome is usually encountered in children. It very rarely occurs in adults. 23 cases are found in the literature and analyzed: clinical signs are the same as in infantile observations. Prognosis in some cases is surprisingly very good when only the skin is involved.

[Sarcoidosis with extensive ulcerating and atrophying cutaneous manifestations (of the Pick-Herxheimer type) and with cardiac and muscular involvement. About one case (author's transl)]

The authors report an unusual case of chronic sarcoidosis with skin ulcerations and atrophic lesions simulating Pick-Herxheimer's disease. Other severe manifestations are found: cardiac involvement with conduction disturbances and myocardial failure, and muscular involvement which responded well to corticosteroid therapy.

[Multicentric reticulo-histiocytosis; review of recent literature (since 1969)]

The review of recent literature (since 1969) shows 35 cases of multicentric reticulo-histiocytosis. This entity was first described as a dermatological disease, then as a dermatoarthritis. It is in fact a systemic disease which can involve many organs but is sometimes monosymptomatic. Its fatal outcome is, sometimes, the result of a disseminated neoplasia or a lymphoma. Its clinical and microscopic features allow to distinguish it from solitary reticulo-histiocytoma, generalized eruptive histiocytoma, congenital reticulo-histiocytosis of Hashimoto and Pritzker and familial histiocytic dermato-arthritis of Zayid.

[Shulman's syndrome: fasciitis with eosinophilia, pseudoscleroderma with eosinophilia]

The authors report two cases of the Shulman's syndrome. Twenty one cases of this new entity are found in the literature. The main signs are the acute painful onset after an unusual physical exertion, the development of fasciitis, and (or) myositis, and (or) scleroderma of limbs, the absence of Raynaud's phenomenon, visceral involvement, constant eosinophilia and hypergammaglobulinemia; the prognosis is good with an improvement sometimes spontaneous or coincident with prednisone therapy. One of the observations is interesting by the association with Gougerot-Sjogren's syndrome, and a familial case of morphea. The prognosis in this case is mediocre: failure of corticotherapy, and incomplete remission with cyclophosphamide.

Cutaneous manifestations of idiopathic hemochromatosis. Study of 100 cases

Skin manifestations of idiopathic hemochromatosis (IH) are presented in 100 cases with emphasis on the previously unrecognized high frequency of ichthyosis-like states and koilonychia. In 50 cases with treated and nontreated groups, histological siderosis and clinical skin pigmentation were found to decrease postphlebotomy whereas melanosis, histologically, did not. By skin biopsy in 50 cases versus controls, the location of siderosis in eccrine sweat glands seems specific for IH providing a strong basis for a probable diagnosis of the disease. There are correlations between skin manifestations and other signs of the disease.