Topical application of 1,25-dihydroxyvitamin D3 (calcitriol) is an effective and reliable therapy to cure skin lesions in psoriatic children

Head-to-Head Comparison of Tazarotene and Calcitriol with or without Sequential Therapy in Mild-to-Moderate Psoriasis: A Randomized Open-label Study

Objective

Psoriasis is an autoimmune disease that causes rapid turnover of skin cells. It is a chronic disease that affects a patient's quality of life significantly and frequently requires long-term treatment. The study on sequential therapy with tazarotene 0.1% and calcitriol 0.0003% has not been tried so far; hence, we designed this study to compare the safety and efficacy of sequential therapy with tazarotene 0.1% cream and calcitriol 0.0003% ointment versus monotherapy in mild-to-moderate stable plaque psoriasis (SPP). The objective of this study was to compare the safety and efficacy of topical sequential treatment with tazarotene followed by calcitriol, topical calcitriol followed by tazarotene, tazarotene monotherapy, calcitriol monotherapy, and compare the safety and efficacy of the sequential therapies with monotherapies.

Methods

The study was a single center, prospective parallel-group, active control, randomized study of 16 weeks duration (treatment for 8 weeks and follow-up for 16 weeks), randomized to either of the four groups, i.e., tazarotene 0.1% for 4 weeks followed by calcitriol 0.0003% for 4 weeks or calcitriol 0.0003% for 4 weeks followed by tazarotene 0.1% for 4 weeks or tazarotene 0.1% for 8 weeks or calcitriol 0.0003% for 8 weeks. Both tazarotene and calcitriol were applied once daily in all the groups.

Findings

There was no significant difference with regard to age and duration of illness among the four treatment groups. Statistically significant improvement was observed in erythema, scaling, and induration scores, and Physician`s global assessment scale at 8 weeks and 16 weeks as compared to baseline in tazarotene - calcitriol, calcitriol - tazarotene, and calcitriol versus tazarotene groups.

Conclusion

This study concluded that topical treatment with tazarotene 0.1% and calcitriol 0.003% was efficacious in treating mild-to-moderate SPP as both sequential and monotherapy. However, topical treatment with tazarotene as monotherapy was the least efficacious.

Off-Label Treatments for Pediatric Psoriasis: Lessons for the Clinic

Psoriasis is a chronic inflammatory skin disease that affects up to 1.2% of children and adolescents. The treatment options for childhood psoriasis are often based on the same principles as in adults. However, most data on safety and efficacy derive from adult studies, and only a few of the frequently used treatments have achieved approval for use in children. The aim of this study was to review the current literature on off-label treatments for psoriasis in children and adolescents. We searched PubMed and identified 50 studies on off-label treatments. Of these, 23 studies were clinical trials (four randomized). There are only a small number of available studies on off-label treatments for children and adolescents with psoriasis, and many of these are retrospective reviews with few participants. Despite the current lack of studies, we still recommend the use of unapproved treatments since we have clinical experience with treatments such as topical corticosteroids, vitamin D analogs, and methotrexate that have shown promising effects. Regular clinical trials are needed to investigate the safety and efficacy of unapproved treatments. Due to The Pediatric Investigation Plans issued by The European Union, new drugs developed by pharmaceutical companies are required to undergo clinical trials in a pediatric population to get their application for marketing authorization processed. This will hopefully lead to much more data on the efficacy and safety of the new treatments, including treatments for children and adolescents with psoriasis.

Use of topical therapies for pediatric psoriasis: A systematic review

Psoriasis is one of the most common chronic skin diseases, affecting 1%-3% of the general population. It can have a significant negative impact on a patient's quality of life, and in approximately 30% of patients first symptoms can be traced back to childhood. We have performed a comprehensive literature search using the MEDLINE database in order to ascertain the efficacy and adverse reactions of topical treatments in pediatric psoriasis. A total of 13 relevant articles were identified on the following topical agents: corticosteroids, calcineurin inhibitors, vitamin D analogs, and dithranol. Corticosteroids achieved clearance in 72.7% of patients. Calcitriol lead to a 57.2%-100% mean improvement in severity, and calcipotriol to 52%-64%. Combination of calcipotriol and corticosteroids achieved an improvement in mean severity ranging between 32.1% and 80%. Treatment with tacrolimus lead to an >50% improvement. Finally, short contact dithranol lead to a variable response in clearance between different studies, ranging between 3.7% and 81%. No serious adverse reactions were documented, the most common local reaction being irritation. Pediatric psoriasis is a common and challenging condition with no easy and definitive solution. Topical agents are safe, easy to use, readily available and cheap. However, they need to be applied repeatedly, may cause skin irritation, and can be messy. Based on the results presented above, we recommend utilizing all the available topical options before escalating to systemic treatments.

Diagnosis and treatment of pediatric psoriasis: current and future

Psoriasis is a common yet complex inflammatory dermatosis that may be seen in infants, children, and adolescents. The clinical presentation and course may be quite variable, and while patients with mild disease are often easily managed, those with recalcitrant or more severe disease often present a therapeutic dilemma given the number of therapies available and the relative lack of data on the efficacy and safety of use of these therapies in children. This review presents the reader with an overview of the current understanding of the pathophysiology, diagnosis, and treatment of pediatric psoriasis, with an emphasis on the available data in the literature that pertains to the use in children of currently available topical and systemic therapies, including topical corticosteroids, vitamin D analogs, phototherapy, systemic immunosuppressive medications, and biologic agents.

Vitamin D analogs in the treatment of psoriasis: Where are we standing and where will we be going?

Vitamin D and analogs exert in the skin and other tissues potent effects on cellular differentiation and proliferation. Moreover, these compounds regulate apoptosis and exert immunomodulatory effects. During the last decades, it has convincingly been shown that vitamin D compounds are effective and safe in the topical treatment of psoriasis, where they nowadays represent a standard therapy. This review summarizes laboratory and clinical investigations related to the treatment of psoriasis with calcitriol or analogs. Additionally, promising concepts for the development of new vitamin D analogs are discussed. As a matter of fact, the final goal to create strong antiproliferative or antiinflammatory acting vitamin D analogs that exert only minor calcemic activity has not been reached until today. New agents that may activate selective vitamin D signalling pathways but may exert only negligible calcemic activity would declare a new era in dermatologic therapy and may also be effective in the topical or systemic treatment of various inflammatory skin diseases including atopic dermatitis and in various cutaneous malignancies, including lymphomas, squamous cell carcinoma or basal cell carcinoma.

Therapy of psoriasis in childhood and adolescence - a German expert consensus

Psoriasis of childhood shows an annual prevalence of 0.71 % and accordingly has to be regarded as a frequent chronic inflammatory skin disorder of this age. The impact on the quality of life as well as development of the afflicted children and their parents is evident. On the other side, therapy is demanding with regard to the specific juvenile metabolism, physical development and skin penetration of topical drugs. Long-term treatment at an early age has to be critically judged regarding the chronicity of the disease. Topical corticosteroids, alternatively dithranol may be used first-line, followed by vitamin D derivatives. A combination with UV-light, preferably UV-B, has to be decided on an individual basis. Systemic treatment may be initiated in recalcitrant disease with methotrexate and cyclosporine where long-term experience is available from juvenile rheumatology and transplantation medicine. Alternatively fumaric acid esters or retinoids are available. Rehabilitation procedures will help the children and their parents to cope with the disease and its treatment. The different treatment options are presented here as a German expert consensus, as clinical studies are hardly available and only a few therapeutics are licensed for this age. In any case the therapy has to be individually planned and decided together with the patients and their parents to gain maximal safety, comfort and success.

Epidemiology and prescribed treatments in childhood psoriasis: a survey among medical professionals

INTRODUCTION

A study was conducted to explore the epidemiology of childhood psoriasis in general practitioners (GPs) and dermatological practice in the region of our academic medical centre. The treatments used by GPs and dermatologists in juvenile psoriasis were investigated.

METHODS

A questionnaire was sent to 229 GPs and 73 dermatologists. Questions were addressed about the prevalence of childhood psoriasis and treatments used in this disease.

RESULTS

Seventy-three questionnaires were completed. The response rate was 17.0% for GPs and 46.6% for dermatologists. Almost one-third of all GPs have seen one or more patients with juvenile psoriasis under the age of 11 in their own patient population, in contrast to more than 80% of the dermatologists. Extrapolating the results implied an estimated prevalence of childhood psoriasis of 0.17% in the overall Dutch population. Topical corticosteroids were used by 46.2% of GPs and by 91.2% of dermatologists. Vitamin D analogues were prescribed by GPs and dermatologists in 15.4% and 73.5% of cases, respectively. Systemic medication for juvenile psoriasis was only used by 20.6% of dermatologists.

CONCLUSIONS

Calculated for the Dutch population, there should be approximately 27,500 children with psoriasis in The Netherlands. Topical corticosteroids were the first-choice treatment for both GPs and dermatologists, whereas vitamin D analogues were used as a second-choice topical therapy. Systemic medication was only sparsely prescribed by dermatologists.

Therapieoptionen der Psoriasis im Kindes- und Jugendalter. Therapy options for psoriasis in childhood and adolescence

Up to 30% of all psoriatic patients show their first symptoms during childhood and adolescence. In 1/4 of these children, psoriatic lesions appear within the first two years of life. The treatment of pediatric psoriasis differs considerably in several ways from that of adults. Not only the age and intensity but also physical development, prognostic criteria and social background should be considered. Standard procedures, clinical trials of high quality and therapeutic guidelines for psoriasis in childhood are still lacking. This review surveys the therapeutic management of pediatric and juvenile psoriasis. Current topical and systemic therapy options are critically reviewed. Prevention as well as enhancement of quality of life are also considered.

Long-term safety of topical calcitriol 3 microg g(-1) ointment

To assess the topical and systemic safety and tolerance of twice-daily application of 3 microg g(-1) 1alpha25-dihydroxyvitamin D3 (calcitriol) ointment (Silkis ointment, Galderma Laboratories) in the long-term treatment of patients suffering from chronic plaque psoriasis, we performed an open-design, multicentre study. Two hundred and fifty-three patients (155 males, 98 females) treated all their psoriatic lesions, except for those on the head and scalp, for up to 78 weeks. No serious adverse events were reported: 37 patients (14.6%) had a transient skin irritation reaction on one or more occasions during the study that resulted in study withdrawal for seven of them. The baseline/endpoint analyses showed no clinically relevant changes in measures of calcium and phosphorus homeostasis and renal function. Slight hypercalcaemia was observed in five (2%) patients: in four of these patients, serum albumin-adjusted total calcium levels normalized during treatment. In conclusion, twice-daily calcitriol 3 microg g(-1) ointment is safe and well tolerated in the long-term treatment of chronic plaque psoriasis.

Pediatric dermatology: advances in therapy

Several recent therapeutic advances in pediatric dermatology have been made. Of particular importance are new developments in the use of antimicrobials, antivirals, antifungals, retinoids, calcipotriene, and intravenous gamma globulin. We review safety and efficacy data of these drugs in their use in children with cutaneous disease.