Calcipotriol treatment of confluent and reticulated papillomatosis (Gougerot-Carteaud syndrome)

Nonpsoriatic Uses of Calcipotriol

Background:

Calcipotriol is a synthetic vitamin D3 analog that binds to vitamin D receptors in epidermal cells. In vitro studies have shown that calcipotriol stimulates terminal cell differentiation and has antiproliferative effects. In vivo, calcipotriol has been shown to reduce the number of cycling epidermal cells. Calcipotriol also has less effect on calcium metabolism than calcitriol, which is the natural, bioactive, 1,25-dihydroxyvitamin D3.

Objective:

These properties make calcipotriol an ideal candidate for the topical treatment of hyperproliferative skin disorders. While it has been approved for topical use in psoriasis, its potential for use in other dermatological disorders has not yet been fully investigated.

Conclusion:

This survey of the literature suggests that calcipotriol may show promise in the treatment of other conditions involving abnormal keratinization and hyperproliferation of epidermal cells. While some of these disorders are rare, and therefore difficult to study, further study into the nonpsoriatic uses of calcipotriol may be rewarding.

Targeting the vitamin D endocrine system (VDES) for the management of inflammatory and malignant skin diseases: An historical view and outlook

Vitamin D represents one of the major driving factors for the development of life on earth and for human evolution. While up to 10-20 % of the human organism's requirements in vitamin D can be obtained by the diet (under most living conditions in the USA and Europe), approximately 90 % of all needed vitamin D has to be photosynthesized in the skin through the action of the sun (ultraviolet-B (UV-B)). The skin represents a key organ of the human body's vitamin D endocrine system (VDES), being both the site of vitamin D synthesis and a target tissue for biologically active vitamin D metabolites. It was shown that human keratinocytes possess the enzymatic machinery (CYP27B1) for the synthesis of the biologically most active natural vitamin D metabolite 1,25-dihydroxyvitamin D₃ (1,25(OH)₂D₃), representing an autonomous vitamin D₃ pathway. Cutaneous production of 1,25(OH)₂D₃ may exert intracrine, autocrine, and paracrine effects on keratinocytes and on neighboring cells. Many skin cells (including keratinocytes, sebocytes, fibroblasts, melanocytes, and skin immune cells) express the vitamin D receptor (VDR), an absolute pre-requisite for the mediation of genomic effects of 1,25(OH)₂D₃ and analogs. VDR belongs to the superfamily of trans-acting transcriptional regulatory factors, which includes the steroid and thyroid hormone receptors as well as the retinoid X receptors (RXR) and retinoic acid receptors (RAR). Numerous studies, including cDNA microarray analyses of messenger RNAs (mRNAs), indicate that as many as 500-1000 genes may be regulated by VDR ligands that control various cellular functions including growth, differentiation, and apoptosis. The observation that 1,25(OH)₂D₃ is extremely effective in inducing the terminal differentiation and in inhibiting the proliferation of cultured human keratinocytes has resulted in the use of vitamin D analogs for the treatment of psoriasis. This review gives an historical view and summarizes our present knowledge about the relevance of the VDES for the management of inflammatory and malignant skin diseases.

Off-label uses of topical vitamin D in dermatology: a systematic review

BACKGROUND

Topical vitamin D is approved by the US Food and Drug Administration for the treatment of psoriasis but is also used off-label in the treatment of a variety of cutaneous diseases despite a lack of evidence-based guidelines.

OBJECTIVE

The objective of this study was to provide evidence-based clinical guidelines for the off-label use of topical vitamin D in the treatment of dermatologic disease.

METHODS

A systematic literature review was conducted via the MEDLINE, Embase, and CENTRAL databases for off-label uses of topical vitamin D analogues in the treatment of dermatologic disease other than psoriasis. The data were synthesized, and evidence-based recommendations were rendered according to the highest level of evidence available.

RESULTS

A total of 165 articles met the inclusion criteria. A moderate to strong recommendation was given for the use of topical vitamin D in combination with corticosteroids and phototherapy in vitiligo and as monotherapy for various ichthyoses, morphea, pityriasis alba, prurigo nodularis, and polymorphous light eruption. There is evidence showing that topical vitamin D is ineffective in the treatment of actinic keratosis, seborrheic keratosis, lichen planus, seborrheic dermatitis, alopecia areata, chemotherapy-induced alopecia, and hypertrophic scars.

CONCLUSION

Topical vitamin D analogues have an important role in the off-label treatment of dermatologic disease, but higher quality studies are still required.

Pruritic eruption with reticular pigmentation: confluent and reticulate papillomatosis

A 28-year-old man presented with a 2-year history of a pruritic eruption on his neck, chest, back, axillae, and antecubital and pubic areas. The patient had been previously treated with topical and systemic antifungal therapy for a long time, but showed no response. Examination revealed the typical clinical and histological features of confluent and reticulate papillomatosis. The patient responded well to oral doxycycline.

Confluent and reticulated papillomatosis : a review of the literature

Confluent and reticulated papillomatosis (CARP) was first described >60 years ago. It is distinct from acanthosis nigricans. This article presents the results of a review of the literature in MEDLINE through May 2006 using the terms 'confluent and reticulated papillomatosis', 'reticulated and confluent papillomatosis of Gougerot and Carteaud', and 'reticulated papillomatosis'. A recent report has linked the presence of Dietzia spp. (family: Dietziaceae; suborder: Corynebacterineae; order: Actinomycetales) in the skin to CARP. CARP has also been linked to defects in keratinization. Other possible causes of CARP that have been suggested but seem less likely include endocrine abnormalities, Pityrosporum, a reaction to UV light, and a variation of cutaneous amyloidosis. CARP has been reported worldwide and occurs in both sexes, all age groups, and all races. The disorder can initially manifest as hyperkeratotic or verrucous papules that coalesce to form a reticular pattern peripherally and confluent plaques centrally. Although a variety of treatments for CARP exist, oral minocycline 50-100mg twice daily has been the preferred treatment. However, recent reports of the effectiveness of azithromycin 250-500mg three times weekly may make azithromycin the preferred treatment for CARP, since it has a more benign adverse effect profile than minocycline. Other effective antibacterial treatments include fusidic acid 1000mg daily, clarithromycin 500mg daily, erythromycin 1000mg daily, tetracycline 500mg twice daily, and cefdinir 300mg twice daily. If a recent finding that CARP is caused by a bacterial microorganism is replicated, treatment should likely be determined by bacterial sensitivities, antibacterial adverse effect profiles, and cost considerations. Other oral treatments of CARP that are effective but currently disfavored because of the effectiveness of minocycline include isotretinoin, acitretin, and etretinate. There have been mixed reports regarding the effectiveness of topical treatments, which include selenium sulfide, ketoconazole cream, tretinoin, tazarotene, tacalcitol, and calcipotriene (calcipotriol).

Confluent and reticulate papillomatosis (Gougerot-Carteaud syndrome): a minocycline-responsive dermatosis without evidence for yeast in pathogenesis. A study of 39 patients and a proposal of diagnostic criteria

BACKGROUND

Confluent and reticulate papillomatosis (CRP) (Gougerot-Carteaud syndrome) is a disorder that has been characterized in only small cohorts of patients.

OBJECTIVES

Better to characterize the clinical and pathological findings of the disorder.

METHODS

We retrospectively reviewed the clinical presentation, response to treatment and histological findings of patients presenting to Mayo Clinic (Rochester, MN, U.S.A.) with CRP.

RESULTS

The disorder was diagnosed in 39 patients between 1972 and 2003. Mean age at onset of the skin eruption was 15 years (range 8-32); 21 patients (54%) were male; most were white; most (33) presented for reasons of cosmesis; and eight described the rash as mildly pruritic. At presentation, the skin eruption had been present for a mean of 3.1 years (range 3 months-20 years) and had been recalcitrant to treatment, including antifungal treatment. Typical objective findings were scaling brown macules and patches and velvety papules and plaques, reticulated and papillomatous at least in part, involving the upper trunk, axillae and neck. The most frequent initial diagnostic impressions were tinea versicolor, acanthosis nigricans and CRP. Scales in 32 cases were examined with potassium hydroxide: eight (25%) showed hyphae, and 24 (75%) did not. Skin biopsy specimens from 21 patients showed variable degrees of hyperkeratosis, acanthosis and papillomatosis. Minocycline was prescribed for 22 patients, of whom 14 of 18 (78%) had complete clearing of the skin eruption and four (22%) a partial response. The skin eruptions recurred after stopping treatment in six patients.

CONCLUSIONS

CRP occurs predominantly in young adults and teenagers, with cosmetically displeasing brown scaling patches and plaques affecting the neck, upper trunk and axillae. Frequently, the diagnosis is delayed and the disorder not recognized by physicians, including dermatologists. Clinically, the eruption is most often confused with tinea versicolor. Potassium hydroxide staining of the scale is negative in the majority of cases, implying that fungi are not involved in the pathogenesis of this condition, as has been previously proposed. It is important to recognize this disorder, because minocycline therapy is highly effective in most patients. Criteria for the diagnosis are proposed.

Study of the skin disease spectrum occurring in an Afro-Caribbean population

BACKGROUND

There is a scarcity of recent up-to-date studies on the incidence of skin disease among Afro-Caribbeans.

METHODS

One thousand patients were retrospectively studied for the commonest diagnoses made over a 5-month period from January to May 2001.

RESULTS

The commonest skin diseases seen were acne vulgaris (29.21%), seborrhoeic eczema (22.02%), pigmentary disorders (16.56%), and atopic eczema (6.1%). Other notable common diagnoses included keratosis pilaris, tinea infection, hirsuitism, folliculitis keloidalis nuchae, viral warts, dermatosis papulosa nigra, and confluent and reticulate papillomatosis.

CONCLUSION

The pattern of skin disease seen in the Afro-Caribbean population studied, more closely resembles those seen in developed countries than those seen in developing countries.

Confluent and reticulated papillomatosis (Gougerot-Carteaud) successfully treated with tacalcitol

Confluent and reticulated papillomatosis (CRP) is a rare dermatosis of unknown aetiology whose relationship to Malassezia furfur is still debated. Antifungal agents, antibiotics, retinoids, and, more recently, calcipotriol have been successfully used as treatment. The authors report on a 14-year-old female with confluent and reticulated papillomatosis in whom M. furfur was found. Anti-fungal therapy eliminated the fungus, but did not achieve the disappearance of the lesions. Further treatment with tacalcitol was successful, supporting the theory that CRP might be a disorder of keratinization. To the authors' knowledge, this is the first patient treated with tacalcitol for this entity.

The therapeutic potential of calcipotriol in diseases other than psoriasis

BACKGROUND

Calcipotriol is a vitamin D analog, which has antiproliferative and anti- inflammatory effects, and stimulates terminal differentiation. It has been an established treatment for psoriasis since 1991 in Europe and 1994 in the USA.

OBJECTIVE

To assess the clinical efficacy of topical calcipotriol in diseases other than psoriasis.

RESULTS

A total of 36 original papers were found describing 21 different diseases in which the clinical use of calcipotriol ointment was described as having an effect. These papers were predominantly case reports (n = 22) and observational studies (n = 5), but nine papers described small randomized controlled trials.

CONCLUSIONS

Calcipotriol may generally be effective in diseases characterized by pathogenic elements, such as impaired differentiation or increased keratinocyte proliferation, and activated T lymphocytes. This study of the existing literature suggests that randomized, double-blind, placebo-controlled studies of calcipotriol therapy may be worthwhile in a number of diseases.