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

Bioavailability of betamethasone dipropionate when combined with calcipotriol

BACKGROUND

Calcipotriol and corticosteroids are commonly used treatments for psoriasis vulgaris, each with different mechanisms of action. The two agents have shown combined action, but current formulations do not permit simultaneous application. Daivobet (LEO Pharma, Denmark) ointment contains calcipotriol and the corticosteroid, betamethasone dipropionate. Such a formulation may provide convenience and enhanced activity compared with separate applications, but it is essential that the biological activity and bioavailability of either active agent is not adversely affected by the other component.

OBJECTIVE

His study was designed to determine whether the bioavailability of the corticosteroid component of Daivobet was equivalent to that in a corticosteroid-only formulation (Diprosone, Schering-Plough Laboratories, France).

METHOD

A vasoconstrictor assay measuring skin blanching was used to determine bioequivalence.

RESULT

Skin blanching measured either by objective chromametric measurement or visual assessment showed Daivobet to be equivalent to Diprosone.

CONCLUSION

The data indicate that the steroid component of Daivobet is not unfavorably affected by the calcipotriol.

Efficacy of once-daily treatment regimens with calcipotriol/betamethasone dipropionate ointment and calcipotriol ointment in psoriasis vulgaris

BACKGROUND

A two-compound ointment containing calcipotriol 50 micro g g-1 and betamethasone dipropionate 0.5 mg g-1 has recently been shown to be an effective treatment for psoriasis.

OBJECTIVES

This study was designed to investigate efficacy and safety of different treatment regimens with the two-compound product (Daivobet/Dovobet; LEO Pharma, Ballerup, Denmark) and calcipotriol 50 micro g g-1 ointment (Daivonex/Dovonex; LEO Pharma).

METHODS

In total, 972 patients with psoriasis vulgaris were randomized to one of three treatment regimens: group 1, the two-compound product once daily for 8 weeks followed by calcipotriol ointment once daily for 4 weeks; group 2, the two-compound product once daily for 4 weeks followed by 8 weeks of treatment with calcipotriol ointment once daily on weekdays and the two-compound product once daily at weekends; and group 3, calcipotriol ointment twice daily for 12 weeks. The efficacy was evaluated by Psoriasis Area and Severity Index (PASI) and investigators' global assessments of disease severity. The primary response criteria were percentage reduction in PASI and proportion of patients with absent/very mild disease according to the investigators' global assessments after 8 weeks of treatment.

RESULTS

The mean reduction in PASI from baseline to the end of 8 weeks of treatment was 73.3% for group 1, 68.2% for group 2 and 64.1% for group 3. The proportion of patients with absent/very mild disease at the end of 8 weeks of treatment was 55.3% for group 1, 47.7% for group 2 and 40.7% for group 3. For both primary response criteria, group 1 was statistically superior to group 3 (P < 0.001), whereas group 2 did not differ significantly from group 3. The difference between group 1 and group 2 was statistically significant with regard to PASI but not regarding the proportion of patients with absent/very mild disease. Patients receiving initial therapy with the two-compound product achieved the fastest treatment response, and the maximum treatment effect for these patients was seen after 5 weeks. This effect was maintained with continued treatment with the two-compound product for up to 8 weeks. After 12 weeks of treatment, no significant differences were seen between the three groups with regard to reduction in PASI, whereas the proportion of patients with absent/very mild disease in group 2 was superior to that in group 3. Patients receiving therapy with the two-compound product experienced fewer lesional/perilesional adverse drug reactions than the calcipotriol-treated patients (P < 0.001): 10.9% in group 1, 11.5% in group 2 and 22.3% in group 3.

CONCLUSIONS

Two different short-term treatment regimens employing a recently developed two-compound product (calcipotriol/betamethasone dipropionate) provided rapid and marked clinical efficacy and were shown to be safe therapies for psoriasis vulgaris.

The effect of the combination of calcipotriol and betamethasone dipropionate versus both monotherapies on epidermal proliferation, keratinization and T-cell subsets in chronic plaque psoriasis

Several reports have indicated that the combination of calcipotriol ointment and potent or ultrapotent corticosteroids are more effective and better tolerated, as compared to the monotherapies. The aim of the present study was to find out the effect of combination of calcipotriol ointment once daily and betamethasone dipropionate ointment once daily vs. the effect of twice-daily applications of each of the two treatments as monotherapy during a four-week treatment period. Seven patients with chronic plaque psoriasis were included for treatment with the three treatment schedules. Biopsies were taken before treatment and after four weeks of treatment, and markers for epidermal proliferation (Ki-67) and epidermal differentiation (keratin-10) were studied using a quantitative image analysis, and T-cell subsets in epidermis and dermis (CD4, CD8, CD25, CD45RO, CD45RA, CD94, CD161, and CD2) were studied using immunohistochemical scoring. The most impressive clinical result was reached with the combination. Calcipotriol proved to have a major effect on the proliferation marker Ki-67 and differentiation marker keratin-10, whereas the effect on T-cell subsets was more selective with major reductions of CD45RO(+) and CD8(+) T cells. In contrast, the effect of betamethasone dipropionate on the epidermis was restricted to a normalization of differentiation with a highly significant increase of keratin-10 positive epidermal surface without a significant effect on Ki-67 positive nuclei, and the effect on T-cell subsets was restricted to a reduction of natural killer T-cell receptors designated by CD94 and CD161 in the epidermis. The combination of the two treatments did not affect the proliferation marker Ki-67 and keratinization marker keratin-10, beyond the effect of calcipotriol monotherapy. However, the combination had a profound effect on, virtually, all T-cell subsets, beyond the effect of the monotherapies. It is concluded that the action spectra of calcipotriol and betamethasone on the psoriatic plaque are different and that the combination has effects on T-cell subsets, beyond the addition of the effects of monotherapies.

Fixed-dose combination therapy for psoriasis

Fixed-dose combination therapy offers stable products containing two or more medications with different mechanisms of action and safety profiles. It is also convenient for patients since only one product rather than two or more needs to be applied. Topical corticosteroids are often the mainstay of therapy in psoriasis. Diprosalic and Nerisalic contain a topical corticosteroid (betamethasone dipropionate and diflucortolone, respectively) and salicylic acid. A left/right study showed that both products have comparable efficacy. It has also been shown that betamethasone dipropionate + salicylic acid ointment has similar efficacy to clobetasol and calcipotriene (calcipotriol) ointments. Betamethasone dipropionate + salicylic acid lotion has similar efficacy to clobetasol lotion. Faster improvement of scaling, itching, and redness was noted with betamethasone dipropionate + salicylic acid lotion compared with betamethasone dipropionate alone. Dovobet (Daivobet) ointment is a fixed-dose combination product containing betamethasone dipropionate and calcipotriene. Clinical studies have shown that it has greater efficacy and a faster speed of onset than the individual components or tacalcitol. Once daily and twice daily treatments have similar efficacy. Psoriasis Area and Severity Index reductions of approximately 40% after 1 week and 70% after 4 weeks of therapy were consistently noted in six large international studies involving >6000 patients. Betamethasone dipropionate + calcipotriene treatment is associated with approximately 75% less adverse cutaneous events as compared with tacalcitol, 50% less compared with calcipotriene, and a similar number as treatment with betamethasone dipropionate.

Changing paradigms in dermatology: nuclear hormone receptors

Nuclear hormone receptors (NHRs) are a family of proteins that function similarly as nuclear transcription factors. The NHR family includes glucocorticoid receptors, retinoic acid and retinoid receptors, vitamin D receptors, thyroxin receptors, and peroxisome proliferator activated receptors. These proteins are targets for some of the most commonly prescribed medications in dermatology, including corticosteroids, retinoids, and vitamin D analogues, all of which have limiting side effects. Advances in this field have led to better understanding of the mechanisms of NHR therapeutic and toxic effects, receptor subtypes, tissue distribution, and interaction with other molecules. New generations of more specific NHR ligands designed to increase therapeutic efficacy and limit adverse effects have dramatically expanded the clinical application of NHR-targeting drugs. The current understanding of NHRs and future directions for NHR ligands in dermatology are discussed.

[Topical treatment of psoriasis: a systematic update]

Classical topical treatment regimens in psoriasis including dithranol and corticosteroids are widely used and have been supplemented in recent years by topical vitamin D preparations, by vitamin D analogues and topical retinoids. The combination of these preparations with each other, with UV light or with systemic drugs often lead to improved effectiveness and tolerability when compared with the respective monotherapy. In private offices, the combination of calcipotriol with various corticosteroids is very commonly prescribed for patients with mild to moderate psoriasis. This combination can be sequentially applied twice daily or--in a newly introduced fixed preparation--once daily. In severe psoriasis requiring systemic treatment a concomitant effective topical treatment regimen can greatly improve the overall longtime management in affected patients.