Development of a new formulation combining calcipotriol and betamethasone dipropionate in an ointment vehicle

Lecithin Organogel: A Promising Carrier for the Treatment of Skin Diseases

Skin is the largest organ of the human body, as it protects the body from the external environment. Nowadays, skin diseases and skin problems are more common, and millions of people are affected daily. Skin diseases are due to numerous infectious pathogens or inflammatory conditions. The increasing demand for theoretical research and practical applications has led to the rising prominence of gel as a semisolid material. To this end, organogels has been widely explored due to their unique composition, which includes organic solvents and mineral or vegetable oils, among others. Organogels can be described as semisolid systems wherein an organic liquid phase is confined within a three-dimensional framework consisting of self-assembled, cross-linked, or entangled gelator fibers. These gels have the ability to undergo significant expansion and retain substantial amounts of the liquid phase, reaching up to 99% swelling capacity. Furthermore, they respond to a range of physical and chemical stimuli, including temperature, light, pH, and mechanical deformation. Notably, due to their distinctive properties, they have aroused significant interest in a variety of practical applications. Organogels favor the significant encapsulation and enhanced permeation of hydrophobic molecules when compared with hydrogels. Accordingly, organogels are characterized into lecithin organogels, pluronic lecithin organogels, sorbitan monostearate-based organogels, and eudragit organogels, among others, based on the nature of their network and the solvent system. Lecithin organogels contain lecithin (natural and safe as a living cell component) as an organogelator. It acts as a good penetration enhancer. In this review, first we have summarized the fundamental concepts related to the elemental structure of organogels, including their various forms, distinctive features, methods of manufacture, and diverse applications. Nonetheless, this review also sheds light on the delivery of therapeutic molecules entrapped in the lecithin organogel system into deep tissue for the management of skin diseases and provides a synopsis of their clinical applications.

Randomized Phase 3 trial demonstrating high efficacy, favourable safety and convenience of a novel calcipotriol and betamethasone dipropionate cream for the treatment of psoriasis

BACKGROUND

The fixed dose combination of calcipotriene (CAL) and betamethasone dipropionate (BDP) is a well-established topical treatment option for psoriasis based on strong scientific rationale for the single agents having complementary efficacy and safety. CAL/BDP PAD-cream is an easily spreadable cream based on PAD Technology™, an innovative formulation and drug delivery system.

OBJECTIVES AND METHODS

A Phase 3, multicentre, randomized, investigator-blind, active and vehicle-controlled trial enrolling 490 patients with mild to moderate psoriasis according to the Physician Global Assessment (PGA) scale was conducted in three European countries. Products were applied once daily for 8 weeks. The aim of the trial was to evaluate the efficacy and safety of CAL/BDP PAD-cream as well as treatment acceptability compared to CAL/BDP gel and PAD-cream vehicle. Primary endpoint was percentage change in modified Psoriasis Area and Severity Index (mPASI) from baseline to Week 8.

RESULTS

The percentage mean change from baseline to Week 8 in mPASI for CAL/BDP PAD-cream (67.5%) was superior compared to PAD-cream vehicle (11.7%; p < 0.0001) and non-inferior to CAL/BDP gel (63.5%). The proportion of patients achieving PGA treatment success (at least two-step improvement to clear or almost clear) after 8 weeks was superior for CAL/BDP PAD-cream (50.7%) compared to PAD-cream vehicle (6.1%, p < 0.0001) and statistically significantly greater than CAL/BDP gel (42.7%, p = 0.0442). Patient-reported psoriasis treatment convenience score (PTCS) for CAL/BDP PAD-cream was rated superior to CAL/BDP gel at Week 8 (p < 0.0001) and the mean change in DLQI from baseline to Week 8 improved statistically significantly more in the CAL/BDP PAD-cream group compared to both PAD-cream vehicle (p < 0.0001) and CAL/BDP gel (p = 0.0110). Safety assessments during the trial demonstrated that CAL/BDP PAD-cream was well-tolerated.

CONCLUSION

CAL/BDP PAD-cream is a novel topical treatment of psoriasis that has a high efficacy and a favourable safety profile combined with a superior patient-reported treatment convenience.

Enhanced Skin Deposition of Betamethasone Dipropionate from a Novel Formulation and Drug Delivery Technology

INTRODUCTION

Effective topical drug delivery is the essence of dermatologic treatment. The drug must be applied to the skin surface, be released from the vehicle, enter the stratum corneum, traverse the epidermis, and enter the dermis pharmacologically intact. New advances have improved emulsion-type formulation and drug delivery technology by encapsulating dispersed oil droplets in a robust multimolecular aqueous film of surfactants, oil, and water, enabling a multifold decrease in surfactant concentration compared to conventional creams. In the research reported here, we studied this new concept, termed polyaphron dispersion (PAD) technology, by comparing skin delivery of betamethasone dipropionate from a novel oil-in-water emulsion system of calcipotriene and betamethasone dipropionate (CAL/BDP) cream to that from a traditional topical suspension (CAL/BDP TS) utilizing in vitro and in vivo detection methods.

METHODS

The amount of BDP released from the CAL/BDP cream and CAL/BDP TS was evaluated using both in vitro Franz cell analysis and in vivo human tape stripping from ten female human volunteers after a single application of CAL/BDP cream or CAL/BDP TS. For the tape stripping analysis, 20 circular tape strips were taken from forearm application sites at 1, 2, 4, and 8 h after application and analyzed for the amount of BDP in the tape strip using liquid chromatography-mass spectrometry (LC-MS).

RESULTS

The in vitro Franz cell analysis demonstrated that the cumulative amount of BDP that diffused through the epidermis was statistically significantly greater for the CAL/BDP cream compared to the CAL/BDP TS at all time points. In addition, consistently higher amounts of BDP were recovered following CAL/BDP cream application than following CAL/BDP TS application at 1, 2, 4, and 8 h following application utilizing the in vivo tape stripping technique.

CONCLUSION

The novel PAD technology-based cream formulation delivered more BDP into the upper stratum corneum and lower epidermis than a traditional topical suspension.

Polyaphron Dispersion Technology, A Novel Topical Formulation and Delivery System Combining Drug Penetration, Local Tolerability and Convenience of Application

Topical formulation and delivery technologies for pharmaceutical application should simultaneously address efficacy, safety and convenience of therapy. This has historically proven to be challenging, since formulation features that drive efficacy often have undesirable consequences for safety and convenience and vice versa. Polyaphron dispersion (PAD) technology is a novel topical formulation and drug delivery system developed with the purpose of preserving these key attributes. PAD formulations are typically oil-in-water dispersions consisting of oil droplets encapsulated in a multi-molecular shell structure. This shell structure protects potentially unstable active molecules solubilized in the oil from hydrolytic degradation. Example data are presented of enhanced drug penetration from PAD formulations, including dermal delivery of calcipotriene, betamethasone dipropionate and tacrolimus as well as ocular delivery of ciclosporin A. Local tolerability is an important safety parameter for topical formulations, where high levels of surfactants can cause skin irritation. In this regard, a key benefit of PAD formulations is the inherent reduced requirement for surfactants to generate stable formulations compared to conventional emulsion systems. Patients with chronic diseases with topical manifestations such as psoriasis or atopic dermatitis have been reported to miss up to 70% of planned topical applications, mainly due to a lack of satisfaction with their therapy. Patients generally prefer light, moisturizing, non-greasy and quickly absorbed vehicles that are simple to use on all body parts. PAD formulations can generally be designed to meet these criteria. In conclusion, PAD technology provides high flexibility in topical drug design and can be applied to several body locations without compromising efficacy, safety or convenience of therapy.

Clinical Trial Register: Clinicaltrials.gov: NCT03802344.

A pooled analysis of randomized, controlled, phase 3 trials investigating the efficacy and safety of a novel, fixed dose calcipotriene and betamethasone dipropionate cream for the topical treatment of plaque psoriasis

BACKGROUND

Plaque psoriasis is a common, chronic and relapsing inflammatory skin disease clinically characterized by erythema and scaling desquamation. As over 90% of psoriasis patients benefit from topical therapies, local treatments continue to play an eminent role in management strategies. One such topical treatment is the fixed dose combination of calcipotriol (CAL) and betamethasone dipropionate (BDP).

OBJECTIVES

Pooled analysis of two different phase 3 clinical trails to compare superiority regarding efficacy, safety and quality of life (QoL) between CAL/BDP PAD-cream and CAL/BDP TS.

METHODS

The data from two phase 3, multicentre, randomized, investigator-blind, active and vehicle-controlled trials enrolling patients with psoriasis were pooled and analysed. Investigational products included a CAL/BDP cream based on PAD™ Technology (PAD-cream) designed for high skin penetration and increased patient preference, an active control (marketed CAL/BDP topical suspension/gel, in the following abbreviated as CAL/BDP TS) and cream vehicle, which were applied once daily for 8 weeks.

RESULTS

Efficacy and safety of the novel CAL/BDP PAD-cream formulation for the topical treatment of psoriasis demonstrated superiority for all efficacy end points after 8 weeks of treatment. PGA treatment success for CAL/BDP PAD-cream (43.2%) was greater than CAL/BDP TS (31.9%; P < 0.0001), the mean per cent reduction in mPASI for CAL/BDP PAD-cream was 64.6% compared to 56.4% for CAL/BDP TS (P < 0.0001) and DLQI 0/1 was obtained by 43.8% in the CAL/BDP PAD-cream group versus 34.2% in the CAL/BDP TS group (P = 0.0005). There was no adverse drug reaction reported with a frequency of >1%, associated with the CAL/BDP PAD-cream.

CONCLUSIONS

The novel fixed dose combination CAL/BDP PAD-cream offers greater efficacy, superior patient QoL and equivalent favourable safety for the topical treatment of psoriasis, in comparison to the currently available topical suspension/gel.

Clinical efficacy and safety of using calcipotriol-betamethasone compounding agent for psoriasis treatment: a systematic review and meta-analysis

The main objective is to evaluate clinical efficacy and safety of using calcipotriol-betamethasone compounding agent for psoriasis treatment through a systematic review and meta-analysis. We searched MEDLINE, Embase, The Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), and WanFang Data from inception till July 31, 2020. Efficacy was evaluated based on primary outcome indicators including skin lesion improvement and overall adverse reaction rate. Secondary outcome indicators included degree of life quality improvement, clinical effectiveness rate, and specific adverse reaction rates. RevMan5.3 was used to perform the meta-analysis. 22 studies finally met our inclusion criteria for the meta-analysis. The results indicated that for short-term treatment, a sequential therapy that uses calcipotriol betamethasone compounding agent and calcipotriol improves PASI score (MD = -0.94, 95% CI - 1.38 ~ - 0.49, P < 0.0001, I² = 49%), comparing with using only calcipotriol. From a drug safety perspective, the difference in overall adverse reaction rate is not significant between the calcipotriol group and the sequential treatment group (RR = 0.50, 95% CI 0.22 ~ 1.14, P = 0.10, I² = 33%). Calcipotriol betamethasone compounding agent may be more effective in plaque psoriasis treatment compared to use only calcipotriol, with no significant difference in adverse reaction rate between the two groups. Although the data were collected from 13 comparison groups, each group may not have sufficient data for a thorough and comprehensive analysis. Further research may be necessary for a more detailed evaluation of effectiveness of using calcipotriol betamethasone compounding agent for plaque psoriasis treatment.

Topical calcipotriol plus betamethasone dipropionate for the treatment of plaque psoriasis: a drug evaluation

Introduction: Psoriasis is an inflammatory skin disease affecting approximately 3.2% of adults in the United States. The mainstay treatment for mild-to-moderate plaque psoriasis (the most common subtype and severity) is topical therapy.Areas covered:The fixed combination calcipotriol plus betamethasone dipropionate (BD) is an effective topical treatment for plaque psoriasis. Two therapies with separate actions - a Vitamin D analog and a high-potency topical corticosteroid - combined into a single medication allows for better efficacy and patient adherence. The treatment is available in ointment, gel, suspension, foam, and cream formulations. The authors elaborate on this and provide their expert perspectives.Expert opinion: Combination calcipotriol/BD offers several advantages over its separate product monotherapies, including better efficacy, safety, and ease of use. Newer calcipotriol/BD formulations include less messy vehicles, thus promoting improved adherence. Further data are needed on whether combination calcipotriol/BD will be cost-effective and whether insurers will place it in the treatment coverage algorithm. Due to its higher price, calcipotriol/BD will likely remain a second-line treatment option after generic topical corticosteroids.

Influence of keratolytics on cutaneous pharmacokinetics of glucocorticoids

BACKGROUND

Keratolytics are often used to accelerate and improve the therapeutic response of hyperkeratotic dermatoses. Keratolytics are a chemically inhomogeneous group of substances and substance mixtures that clinically lead to a decrease in symptoms of a cornification disorder, but mediate different effects. Thus, keratolytic, keratoplastic, keratoemulsifying and keratodiluting effects are distinguished. The physicochemical effects or pharmacological efficacy of the respective keratolytics result in different mechanism as well as risks with regard to local or systemic compatibility. Until now, only little attention has been paid upon selection of keratolytics to the immediate consequences regarding diffusion conditions and pharmacokinetics of sequentially applied topicals, in particular of glucocorticoids.

PATIENTS AND METHODS

This paper deals with the influence of keratolytics on the penetration-time profile of betamethasone dipropionate in sequential application. For this purpose, cutaneous bioavailability was investigated with the Franz chamber test using a tritium-labeled drug depending on the previous application of a keratolytic agent. Comparative data analyses were performed.

RESULTS

It was shown that keratoplastic substances significantly promote diffusion of the glucocorticoid. Keratoemulsifying substance mixtures exert no relevant effects in this regard, while keratodiluting substance mixtures inhibit penetration.

CONCLUSIONS

The targeted selection of a keratolytic can optimize the therapeutic effect and influence the bioavailability of sequentially applied topicals.

Calcipotriol/betamethasone dipropionate formulations for psoriasis: an overview of the options and efficacy data

INTRODUCTION

Psoriasis is a very common chronic inflammatory skin disease affecting up to 3% of the general population with 75% of the psoriasis subjects being affected by a mild form of disease. Hence, topical therapy is the most frequent employed treatment in psoriasis also because it can be easily combined with systemic therapy. In this context, calcipotriol/betamethasone dipropionate (Cal/BD) fixed-dose association represents the first-line treatment due to its efficacy and once-daily application. Different Cal/BD formulations, such as ointment, gel (topical suspension), and aerosol foam, are approved by US Food and Drug Administration.

AREAS COVERED

For this review, relevant English literature (trials, real-life studies, case series, and reviews) regarding Cal/BD different formulations efficacy in psoriasis was searched for through to 28 January 2020. The following database were consulted: PubMed, Embase, the Cochrane Library, Google Scholar, EBSCO, and clinicaltrials.gov.

EXPERT OPINION

Cal/BD formulations are efficacious treatment for psoriasis. Cal/BD aerosol foam shows a higher efficacy compared to Cal/BD ointment or gel formulations, appearing as a game-changer in psoriasis therapy not only for mild disease but also for moderate psoriasis as well as in selected severe cases in combination with systemic treatments.

Sensitivity of Different In Vitro Performance Tests and Their In Vivo Relevance for Calcipotriol/Betamethasone Ointment

PURPOSE

We compared results of in vitro performance testing with results of therapeutic equivalence study for calcipotriol/betamethasone ointment, to evaluate their sensitivity and in vivo relevance.

METHODS

Different in vitro methods were used to evaluate drug release and permeation from the test and reference ointment. Moreover, 444 psoriasis patients were randomized in the therapeutic equivalence study and the parameters of efficacy and safety were compared with in vitro results.

RESULTS

In vitro release and permeation rate of calcipotriol and betamethasone from the test formulation was higher than from the reference product for all methods used (p ≤ 0.05 for calcipotriol and p < 0.01 for betamethasone). Observed batch-to-batch variability of reference product confirmed high sensitivity and discriminatory power of in vitro methods. Higher release and permeation rate of calcipotriol and betamethasone from test product was reflected in the efficacy assessment (mean response difference 4.78 mPASI percentage points), but the observed difference was within the equivalence margins. Systemic exposure to calcipotriol and betamethasone was similar in both treatment groups.

CONCLUSION

The results of in vitro experiments rank orderly correlated with the results of clinical study. In vitro methods are more sensitive and highly discriminatory when compared to in vivo performance.

Simultaneous HPLC Determination of Betamethasone Esters-Containing Mixtures: Analysis of Their Topical Preparations

Topical pharmaceutical preparations containing betamethasone esters are widely prescribed for treatment of severe inflammatory skin conditions. Some betamethasone esters-containing preparations are formulated with either an antibacterial or an antifungal agent or a vitamin D3 derivative. A fast reversed-phase high-performance liquid chromatography method has been developed for the simultaneous determination of three betamethasone esters-containing binary mixtures along with the excipients of their dosage forms using clobetasone butyrate as internal standard. The first mixture was betamethasone valerate and fusidic acid (Mixture I) with chlorocresol as preservative. The second mixture was betamethasone dipropionate (BTD) and clotrimazole (Mixture II) with benzyl alcohol as preservative. The third mixture was BTD and calcipotriol monohydrate (Mixture III). Optimized chromatographic separation was achieved on a Discovery® C18 (4.6 × 250 mm, 5 μm) column, using water: acetonitrile (35:65, v/v) as mobile phase at flow rate of 1 mL/min with UV detection at 230 nm. The method was validated according to ICH guidelines. The regression coefficients were > 0.999 for all drugs. The method was successfully applied for the determination of the studied drugs in bulk, synthetic mixtures and dosage forms. The developed method is accurate, sensitive, selective and precise and can be used for routine analysis in quality control laboratories.

Patient Preferences for Topical Psoriasis Treatments are Diverse and Difficult to Predict

Introduction

Topicals are a mainstay in psoriasis vulgaris treatment and are used concomitantly even in patients receiving systemic therapy. Patient acceptance of topical treatment can impact adherence and, consequently, real-life effectiveness. This study aimed to identify patient preferences for topical treatment attributes and to evaluate patient acceptability of topical treatments.

Methods

This 5-day study evaluated three inactive presentations: fixed combination calcipotriol/betamethasone dipropionate (Cal/BD) ointment vehicle in a tube, Cal/BD gel vehicle in a bottle and Cal/BD gel vehicle in a new Applicator delivery system. Participants with psoriasis on ≥2 locations were recruited, aiming for equal proportions in the categories: male/female; <40/≥40 years old; working/not working. Participants ranked a predefined ‘wish list’ of 13 topical treatment attributes, applied each product and evaluated them in a user survey, indicating how well the products delivered on 16 statements matching the 13 attributes. Afterward, participants indicated preference by psoriasis plaque location.

Results

Patient preferences differed to the extent that the proportion rating an attribute of high importance was similar to the proportion rating the same attribute of low importance. All attributes received similar mean ranking scores. Analysis by demographic characteristics revealed preferences are not associated with gender, age or employment status. Participants did not perceive much difference between the gel and ointment, but expressed preferences for different presentations to treat different plaque locations. The gel Applicator was preferred for 8/14 locations and both gel presentations were strongly preferred for hairy scalp.

Conclusions

Patients with psoriasis have diverse preferences, which cannot be predicted by demographics. Individual patient choice should be considered to increase the acceptability and a range of topical formulations should be available to support treatment adherence and improve clinical outcomes.

Funding

LEO Pharma A/S, Ballerup, Denmark.

Successful treatment of refractory chronic hand eczema with calcipotriol/betamethasone ointment: A report of three cases

Chronic hand eczema (CHE) is a common skin disorder with frequent relapses, and its treatment comprises a challenge due to its uncertain etiology. In particular, certain cases of CHE exhibiting severe keratinization have a very poor response to various treatments. The Daivobet ointment, a complex product comprising calcipotriol and betamethasone, has been successfully used for the treatment of patients with plaque-type psoriasis for ~10 years; however, there are few reports on the effect of the ointment on other skin disorders of abnormal keratinization, such as eczema. The present study reported 3 cases of refractory hyperkeratotic eczema of the hand that did not respond to several treatments, but responded well to topical Daivobet treatment.

Nanocarrier-based hydrogel of betamethasone dipropionate and salicylic acid for treatment of psoriasis

Introduction:

Betamethasone dipropionate (BD) has anti-inflammatory, immunomodulatory, and antiproliferative activity. The aim of the current work was to test the hypothesis that the addition of corticosteroid such as BD and a keratolytic agent such as salicylic acid in nanocarrier based microemulsions formulation would result in enhancement and sustaining of corticosteroid delivery rate leading to better anti-psoriatic activity. Clinical use of BD is restricted to some extent due to its poor permeability across the skin. So to increase its permeation across the skin, microemulsion-based gel formulations were prepared and characterised.

Materials and Methods:

Microemulsions were prepared by aqueous phase titration method, using oleic acid:sefsol (1.5:1), Tween 20, isopropyl alcohol, and distilled water as the oil phase, surfactant, cosurfactant and aqueous phase, respectively. Selected formulations were subjected to physical stability studies and consequently in vitro skin permeation studies. Surface studies of optimized formulation were done by transmission electron microscopy. In vivo anti-inflammatory activity was done by carageenan-induced raw paw edema method.

Results:

The droplet size of microemulsions ranged from 60 to 190 nm. The optimized formulation exhibited viscosity 28.55 ± 2.03 mP, refractive index 1.409, pH 6.4, and conductivity 10^-4 scm^-1. The optimized microemulsion was converted into hydrogel using carbopol 934, and salicylic acid was incorporated into it. Drug deposition in skin was found to be 29.73 μg/mg. Assessment of skin permeation was done by histopathology studies which indicated changes in the structure of epidermal membrane of skin. In vivo anti-inflammatory activity indicated 72.11% and 43.96% inhibition of inflammation in case of developed microemulsion gel and marketed gel, respectively.

Conclusions:

The developed microemulsion gel containing BD and salicylic acid provided sustained and good anti-inflammatory activity for the treatment of psoriasis.

Calcipotriol delivery into the skin with PEGylated liposomes

The D-vitamin analogue calcipotriol is commonly used for topical treatment of psoriasis, but skin penetration is required for calcipotriol to reach its pharmacological target: the keratinocytes in the lower epidermis. Liposomes can enhance the delivery of drugs into the skin, but a major challenge for the development of dosage forms containing liposomes is to maintain the colloidal stability in the formulation. The purpose of this study was to investigate the effect of stabilising liposomes with the lipopolymer poly(ethylene glycol)-distearoylphosphoethanolamine (PEG-DSPE) on the physicochemical properties of the liposomes and the ability to deliver membrane-intercalated calcipotriol into the skin. Inclusion of 0.5, l and 5 mol% PEG-DSPE in the membrane enhanced the colloidal stability of the liposomes without compromising the delivery of calcipotriol from the vehicle into excised pig skin. Calcipotriol-loaded liposomes with 1 mol% PEG-DSPE did even provide for a significantly increased deposition of calcipotriol into the stratum corneum. The size of the liposomes affected the penetration of calcipotriol into the stratum corneum since small unilamellar vesicles enhanced calcipotriol penetration as compared to large multilamellar vesicles, indicating that the liposomes to some extent migrate as intact vesicles into the stratum corneum. However, calcipotriol penetrated the skin better than the lipid component of the liposomes, suggesting that at least a fraction of the drug is released from the liposomes during skin migration. In conclusion, PEGylation is therefore a promising approach for stabilising calcipotriol-containing liposomal dispersions without compromising their favourable skin accumulation properties.

Mechanisms of action of topical corticosteroids in psoriasis

Psoriasis is a lifelong, chronic, and immune-mediated systemic disease, which affects approximately 1-3% of the Caucasian population. The different presentations of psoriasis require different approaches to treatment and appropriate prescriptions according to disease severity. The use of topical therapy remains a key component of the management of almost all psoriasis patients, and while mild disease is commonly treated only with topical agents, the use of topical therapy as adjuvant therapy in moderate-to-severe disease may also be helpful. This paper focuses on the cutaneous mechanisms of action of corticosteroids and on the currently available topical treatments, taking into account adverse effects, bioavailability, new combination treatments, and strategies to improve the safety of corticosteroids. It is established that the treatment choice should be tailored to match the individual patient's needs and his/her expectations, prescribing to each patient the most suitable vehicle.

Heterogeneity in the treatment of moderately severe scalp psoriasis in Scotland - results of a survey of Scottish health professionals

BACKGROUND

Scalp psoriasis is a chronic recalcitrant condition. An aging literature for topical treatments used in clinical practice and no treatment guidelines means there is no current gold standard for its management in Scotland. There are no Scottish data on the resources and costs of treatment of the scalp psoriasis patient.

OBJECTIVE

Conduct a survey of Scottish healthcare professionals to understand how patients are typically managed to support the development of a model estimating the cost-effectiveness of a new treatment for moderately severe scalp psoriasis in Scotland.

RESEARCH DESIGN AND METHODS

Experts from primary and secondary care were invited to participate in an interview programme to collect information on the management of scalp psoriasis in Scotland. This was further informed by Scottish prescribing statistics. Simple descriptive statistics were performed.

RESULTS

Forty-three healthcare professionals (33 from primary care and ten in secondary care) completed the survey which illuminated national prescribing statistics. While an overall 72% response rate was achieved, representation from five of 14 Health Boards was not available. There was significant variation in stated patient pathways but some common themes. Most patients were treated initially with coal tar preparations and shampoos, then often progressing to topical potent corticosteroids. There was no consensus on the order patients might receive topicals thereafter although if referred for specialist review they would typically have been treated with three topicals in primary care first. Treatment in secondary care comprised application of topicals available in primary care or alternative preparations with nurse assistance to improve compliance. Phototherapy and systemic agents were not given to patients with scalp psoriasis alone. Study limitations are not considered to impact on the study observations.

CONCLUSIONS

There was a large variety in first-, second- and third-line agents in primary care in scalp psoriasis although our interview programme and prescribing data confirmed which treatments were most frequently prescribed. Treatment heterogeneity reflects the limitations in current therapies, paucity of evidence-based effectiveness data and lack of clinical guidelines. Experts agreed 'current standard practice' in Scotland was best described as an average across five plausible treatment pathways.

Calcipotriene/betamethasone in the treatment of psoriasis: a review article

Plaque-type psoriasis is a chronic and immune-mediated skin disease affecting approximately 1-3% of the Caucasian population. Most cases are of mild or moderate severity and benefit from local treatment that represents the mainstay therapy. Topical corticosteroids and vitamin D(3) analogues remain the option of choice. Optimization of these treatments is made by the combination of calcipotriene and betamethasone dipropionate. This formulation combines the keratinocyte differentiation and antiproliferative action of the vitamin D(3) analogues with the anti-inflammatory effect of steroids enhancing effectiveness while reducing the side-effect profile of the single topical agent. In this article, we highlight the advantages of the association of calcipotriene and betamethasone in the treatment of localized plaque-type, scalp and nail psoriasis.

Nanoparticles containing anti-inflammatory agents as chemotherapy adjuvants: optimization and in vitro characterization

The pre-administration of dexamethasone (DEX) has previously been shown to enhance the anti-tumor efficacy of chemotherapeutic agents. The delivery of anti-inflammatory agents specifically to tumors via nanoparticle carriers is expected to promote the effectiveness of chemotherapeutic agents while avoiding systemic toxicities. The process for preparing solid lipid nanoparticles containing anti-inflammatory agents using the nanotemplate engineering method was optimized. Due to the solubilization of DEX in the bulk aqueous phase, its more lipophilic palmitate ester was synthesized and incorporated in nanoparticles that included a pegylating agent, PEG6000 mono-stearate, as part of the formulation. The stealth properties of these nanoparticles were demonstrated to be enhanced compared to latex particles by measuring the adsorption of radioiodinated IgG (185 microg vs. 6.7 microg IgG/mg NP). In addition, the uptake of (14)C-labeled nanoparticles by murine macrophages was shown to decrease from 36.6% to 14.7% of the nanoparticles/mg cell protein as the amount of pegylating agent in the formulation increased from 0 to 4 mg/mL. The high loading values and low burst effect observed for these DEX palmitate-containing nanoparticles in addition to their stealth properties are expected to allow for the delivery of sufficient amounts of DEX to tumors to enhance the uptake of chemotherapeutic agents.

Calcipotriol/betamethasone dipropionate in the treatment of psoriasis vulgaris

Psoriasis is one of the most common skin diseases. The mainstay of treatment for the vast majority of patients is topical therapy. A rising first-line treatment modality for psoriasis vulgaris is the two-compound ointment containing calcipotriol 50 mug/g plus betamethasone dipropionate 0.5 mg/g (Dovobet((R)), Daivobet((R)), Taclonex((R))), which combines a vitamin D analog and a corticosteroid. This innovative formulation preserves the activity and bioavailability of the two components and many clinical studies have demonstrated that it has a greater efficacy, tolerability, and a rapid onset of action compared with its individual ingredients or tacalcitol.

Cost-Effectiveness Model of Topical Treatment of Mild to Moderate Psoriasis Vulgaris in Germany

BACKGROUND

Psoriasis vulgaris requires lifelong treatment associated with considerable health cost. Studies showed that a combination of a steroid and a vitamin D(3) analogue is more effective than both compounds in monotherapy.

OBJECTIVE

To determine the cost-effectiveness of a fix calcipotriol/betamethasone combination (Daivobet/Dovobet/Taclonex) compared to a morning/evening non-fix calcipotriol/betamethasone combination in psoriasis treatment.

METHODS

A Markov model (discrete-time stochastic process based on transitions between health states) with 2 treatment arms (Daivobet/Dovobet/Taclonex vs. non-fix calcipotriol/betamethasone) over a 48-week time period was developed. The effectiveness criterion was the number of days with clearance or marked improvement. Clinical and health resource utilisation data were derived from randomised studies.

RESULTS

Treatment with Daivobet/Dovobet/Taclonex showed a higher cost-effectiveness compared to the non-fix combination, even when assuming a maximum compliance for the twice daily non-fix combination and varying the effectiveness of Daivobet/Dovobet/Taclonex by 10%.

CONCLUSION

Psoriasis treatment with a fix calcipotriol/betamethasone combination is more cost-effective than a non-fix morning/evening combination.

Calcipotriol/betamethasone dipropionate for the treatment of psoriasis

The two-compound product calcipotriol/betamethasone dipropionate is arising as a first-line treatment for mild-to-moderate plaque psoriasis. Its beneficial action is attributed to the synergistic effect of its components on keratinocyte proliferation and differentiation, and on inflammation. The good tolerability of the two-compound product is thought to be due to the anti-inflammatory effect of betamethasone. Evidence from short-term (4-12 weeks) and long-term use (> 1 year) has shown a good safety profile. Areas such as the face or skin folds, which are sensitive to the components of the combination, should be avoided. Finally, it is unsuitable for use in unstable psoriasis, in which potent steroids may lead to an increased inflammatory response.