Improvement of psoriasis by a topical vitamin D3 analogue (MC 903) in a double-blind study

Safety and Efficacy of Topical Vitamin D in the Management of Dry Eye Disease Associated With Meibomian Gland Dysfunction: A Placebo-Controlled Double-Blind Randomized Controlled Trial

PURPOSE

The aim of this study was to investigate the safety and efficacy of topical vitamin D in the management of dry eye disease associated with meibomian gland dysfunction (MGD).

METHODS

In this randomized controlled trial, patients with symptomatic MGD were divided into 2 groups to receive topical vitamin D drops or placebo in their randomized eyes. The exclusion criteria consisted of patients with vitamin D deficiency, previous ocular surgery, and patients with ocular diseases affecting the tear film. Patients and researchers were masked to the study groups. The outcomes included the score of Dry Eye Questionnaire (DEQ) 5 and Ocular Surface Disease Index (OSDI), corneal and conjunctival staining score, tear breakup time (TBUT), Schirmer, and MG expressibility score evaluated at baseline and weeks 4 and 8.

RESULTS

Twenty-eight eyes of 28 patients were recruited in each group. In addition to the improvement of subjective parameters in both groups, there was a statistically significantly greater improvement in the vitamin D group compared with control for average scores of OSDI (13.38 ± 7.32 vs. 27.94 ± 7.49) and DEQ5 (9.67 ± 1.86 vs. 14.14 ± 2.45) at week 8 (Ps <0.001). In addition, a significant improvement in TBUT and Schirmer test was observed in both groups in weeks 4 and 8 ( P value <0.05). There was a significant difference between the treatment and control groups after 8 weeks for OSDI, DEQ5, Schirmer, TBUT, corneal fluorescein staining, and MG expressibility score ( P value <0.05).

CONCLUSIONS

The preliminary results of this randomized controlled trial suggested that use of topical vitamin D drops with a lipid vehicle could be safe and might significantly improve the symptoms and signs of dry eye associated with MGD.

Editorial: fixed-dose combination calcipotriol/betamethasone dipropionate foam in the treatment of patients with psoriasis

Video abstract

Relation of Dietary Fatty Acids and Vitamin D to the Prevalence of Meibomian Gland Dysfunction in Japanese Adults: The Hirado-Takushima Study

Intervention studies have shown that n-3 polyunsaturated fatty acid (PUFA) supplementation is effective for the treatment of meibomian gland dysfunction (MGD). Ointment containing an analog of vitamin D has also been found to improve symptoms and signs of MGD. We have now evaluated the relation of MGD prevalence to dietary intake of fatty acids (FAs) and vitamin D among a Japanese population. Subjects comprised 300 adults aged 20 to 92 years residing on Takushima Island. MGD was diagnosed on the basis of subjective symptoms, lid margin abnormalities, and meibomian gland obstruction. Dietary FA and vitamin D intake was estimated with a brief-type self-administered diet history questionnaire. MGD prevalence was 35.3%. Multivariate adjusted odds ratios (95% confidence intervals) between extreme quintiles of intake for MGD prevalence were 0.40 (0.16–0.97) for total fat, 0.40 (0.17–0.97) for saturated FAs, 0.40 (0.17–0.97) for oleic acid, 0.52 (0.23–1.18) for n-3 PUFAs, 0.63 (0.27–1.49) for n-6 PUFAs, 1.32 (0.59–2.95) for the n-6/n-3 PUFA ratio, and 0.38 (0.17–0.87) for vitamin D. Total fat, saturated FA, oleic acid, and vitamin D intake may thus be negatively associated with MGD prevalence in the Japanese.

A Brief History of Psoriasis Management in Canada

Psoriasis is a chronic, inflammatory disease with a varying degree of clinical presentations. Managing psoriasis has always been arduous due to its chronicity and its propensity to relapse. Prior to the development of targeted biologic therapies, there were few effective treatments for psoriasis. Ancient psoriasis therapies included pinetar, plant extracts, psychotherapy, arsenic, and ammoniated mercury. In the 19th century, chrysarobin was developed. Then, in the early half of the 20th century, anthralin and coal tar were in widespread use. In the latter half of the 20th century, treatments were limited to topical first-line therapies, systemic drugs, and phototherapy. However, as the treatment of psoriasis has undergone a revolutionary change with the development of novel biologic therapies, patients with moderate to severe psoriasis have been able to avail therapies with high efficacy and durability along with an acceptable safety profile. This article is a brief historical review of the management of psoriasis prior to the inception of biologics and with the development of novel biologic therapies.

Challenge and perspective: the relevance of ultraviolet (UV) radiation and the vitamin D endocrine system (VDES) for psoriasis and other inflammatory skin diseases

During evolution, the ability of many organisms to synthesize vitamin D photochemically represented, and still represents, a major driving factor for the development of life on earth. In humans because not more than 10-20% of the requirement of vitamin D can be satisfied by the diet (under most living conditions in the US and Europe), the remaining 80-90% need to be photochemically synthesized in the skin through the action of solar or artificial ultraviolet-B (UV-B) radiation. The skin is a key organ of the human body's vitamin D endocrine system (VDES), representing both the site of vitamin D synthesis and a target tissue for biologically active vitamin D metabolites. Human keratinocytes contain 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 mediate intracrine, autocrine and paracrine effects on keratinocytes and on neighboring cells. Many skin cells (including keratinocytes, sebocytes, fibroblasts, melanocytes, macrophages and other skin immune cells) express the vitamin D receptor (VDR), an absolute pre-requisite for exerting genomic effects of 1,25(OH)₂D₃ and analogs. The VDR is a member of the superfamily of trans-acting transcriptional regulatory factors, which also contains the steroid and thyroid hormone receptors as well as the retinoid-X receptors (RXR) and retinoic acid receptors (RAR). A large body of evidence, including cDNA microarray analyses of mRNAs, indicates that as many as 500-1000 genes may be controlled by VDR ligands that regulate a broad variety of cellular functions including growth, differentiation, and apoptosis. Clinical and laboratory investigations, including the observation that 1,25(OH)₂D₃ is very effective in inducing the terminal differentiation and in inhibiting the proliferation of cultured human keratinocytes have resulted in the use of 1,25(OH)₂D₃ and analogs for the treatment of psoriasis. Focussing on the UV-induced cutaneous synthesis of vitamin D, this review gives an update on the relevance of the VDES and of UV radiation for the management of psoriasis and other inflammatory skin diseases.

Molecular action of isoflavone genistein in the human epithelial cell line HaCaT

Due to its strong proliferation-reducing effects on keratinocytes, and also anti-inflammatory properties, the isoflavone genistein has already been proposed as a possible antipsoriatic compound. As there is still no detailed information on this topic, we examined the effects of genistein by using an in vitro model of both, normal and "psoriasis-like" keratinocytes at this stage of our work exhaustively testing the selected flavonoid in a mono-treated experimental design. Gene expression studies revealed transcriptional changes that confirms known disease-associated pathways and highlights many psoriasis-related genes. Our results suggested that aberrant expression of genes contributing to the progress of psoriasis could be improved by the action of genistein. Genistein prevented "cytokine mix" as well as TNF-α-induced NF-κB nuclear translocation, with no effect on the PI3K signaling cascade, indicating the luck of turning this pathway into NF-κB activation. It could have attenuated TNF-α and LPS-induced inflammatory responses by suppressing ROS activation. Regardless of the type of keratinocyte stimulation used, reduction of cytokine IL-8, IL-20 and CCL2 production (both at RNA and protein level) following genistein treatment was visible. Because investigations of other groups supported our commentary on potential administration of genistein as a potential weapon in the armamentarium against psoriasis, it is believed that this paper should serve to encourage researchers to conduct further studies on this subject.

Inhibition of IL-17-committed T cells in a murine psoriasis model by a vitamin D analogue

BACKGROUND

A better understanding of the means by which topical vitamin D analogues exert their therapeutic effect on psoriasis is of theoretical and practical importance.

OBJECTIVE

We sought to clarify whether and how the topical vitamin D analogue calcipotriol (CAL) controls the IL-17A-mediated pathogenesis of murine psoriasis-like dermatitis in vivo.

METHODS

Psoriasis-like dermatitis was induced by the topical application of an imiquimod (IMQ)-containing cream on the murine ear for 4 to 6 consecutive days. For topical CAL treatment, mice were treated daily with CAL solution on the ear before IMQ application.

RESULTS

Mice treated topically with CAL exhibited much milder IMQ-induced psoriasis-like dermatitis compared with vehicle-treated mice, with impaired accumulation of IL-17A-committed T (T17) cells in the lesional skin. The IMQ-induced upregulation of Il12b and Il23a was marked in the epidermis and was abrogated by CAL application, suggesting CAL-mediated suppression of IL-23 expression. CAL inhibited Il12b and Il23a expression by Langerhans cells ex vivo stimulated with IMQ and CD40 cross-linking. Topical CAL also inhibited T17 cell expansion in the draining lymph nodes of IMQ-treated skin, implying a possible effect on T17 cell-mediated dermatitis at distant sites. In fact, topical CAL application on the IMQ-treated left ear resulted in amelioration of T17 cell accumulation and psoriasis-like dermatitis in the right ear subsequently treated with IMQ.

CONCLUSION

Topical CAL can exert its antipsoriatic effect on CAL-treated lesions and, concomitantly, distant lesions by attenuating the T17 cell accumulation in both CAL-treated lesions and draining lymph nodes.

A randomized, double-blind, placebo-controlled trial of the effect of monthly vitamin D supplementation in mild psoriasis. J DERMATOL TREAT 2017;29:324-328. [PMID: 28849682 DOI: 10.1080/09546634.2017.1373735]

PURPOSE

To investigate the clinical effect of vitamin D₃ supplementation on psoriasis from a community-dwelling population.

MATERIALS AND METHODS

Participants with psoriasis in a large randomized controlled trial examining the effect of vitamin D₃ supplementation (100,000 IU monthly) in adults aged 50-84 years were invited to participate in a psoriasis sub-study over 12 months. The primary outcome was the Psoriasis Area and Severity Index (PASI) and secondary outcomes were Physicians Global Assessment (PGA), Dermatology Life Quality Index (DLQI), and Psoriasis Disability Index (PDI). Trial identification number ACTRN12611000402943.

RESULTS

Twenty-three were allocated to vitamin D and 42 to placebo. There was no significant difference at baseline between the two groups. Mean (SD) baseline 25-hydroxyvitamin D was 65.7 (25.7) nmol/L. There were no significant differences (p > .05) between the groups in all of the psoriasis outcome measures. Mean scores [95% CI] at 12 months for the Placebo versus Vitamin D groups: PASI 2.2 [1.4, 3.0] versus 2.1 [1.0, 3.2]; PGA 1.4 [1.1, 1.7] versus 1.5 [1.1, 1.9]; PDI 2.1 [0.9, 3.2] versus 1.9 [0.4, 3.4]; and DLQI 2.5 [1.4, 3.6] versus 2.0 [0.5, 3.4].

CONCLUSION

Vitamin D₃ supplementation (100,000 IU per month) is not recommended as a treatment for mild psoriasis.

Extraskeletal actions of vitamin D

The vitamin D receptor (VDR) is found in nearly all, if not all, cells in the body. The enzyme that produces the active metabolite of vitamin D and ligand for VDR, namely CYP27B1, likewise is widely expressed in many cells of the body. These observations indicate that the role of vitamin D is not limited to regulation of bone and mineral homeostasis, as important as that is. Rather, the study of its extraskeletal actions has become the major driving force behind the significant increase in research articles on vitamin D published over the past several decades. A great deal of information has accumulated from cell culture studies, in vivo animal studies, and clinical association studies that confirms that extraskeletal effects of vitamin D are truly widespread and substantial. However, randomized, placebo-controlled clinical trials, when done, have by and large not produced the benefits anticipated by the in vitro cell culture and in vivo animal studies. In this review, I will examine the role of vitamin D signaling in a number of extraskeletal tissues and assess the success of translating these findings into treatments of human diseases affecting those extracellular tissues.

Clinical safety and efficacy of vitamin D3 analog ointment for treatment of obstructive meibomian gland dysfunction

Background

Hyperkeratinization is a major cause of obstructive meibomian gland dysfunction (oMGD) and results in degenerative gland dilation and atrophy without inflammation. Ointment containing 1,25-dihydroxy-22-oxavitamin D3 (maxacalcitol), a noncalcemic analog of the active form of vitamin D3, is applied for the treatment of hyperkeratotic cutaneous conditions such as psoriasis and ichtyosis because it suppresses the proliferation and promotes the differentiation of keratinocytes through interaction with the vitamin D receptor. The aim of the present study was to evaluate the safety and efficacy of maxacalcitol ointment for the treatment of oMGD.

Methods

Six eyes of six healthy male subjects (mean age ± SD, 36.4 ± 10.8 years) and 12 eyes of eight oMGD patients (five men and three women; mean age ± SD, 55.6 ± 13.2 years) were enrolled in the study. Maxacalcitol ointment was applied to the upper and lower lid margins twice a day for 8 weeks. Subjective symptoms, lid margin abnormalities, tear film breakup time (BUT), ocular surface staining, meibum grade, Schirmer test value, and meibomian gland area were evaluated in the oMGD patients before, during, and after the treatment period.

Results

Severe adverse effects of ointment application were not observed in the healthy subjects or oMGD patients. The clinical scores for plugging of meibomian gland orifices and lid margin vascularity as well as BUT, meibum grade, and meibomian gland area were significantly improved in oMGD patients after the 8-week treatment period compared with pretreatment values (P values of <0.001, 0.020, 0.030, 0.020, and 0.017, respectively).

Conclusions

Topical eyelid application of an analog of the active form of vitamin D3 was found to be safe as well as to improve the condition of patients with oMGD. Such ointment thus warrants further evaluation as a potential new treatment option for this condition.

Trial registration

This study was registered with the UMIN database (ID: UMIN000016230) on 16 January 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-017-0482-7) contains supplementary material, which is available to authorized users.

Calcipotriol in the Treatment of Psoriasis of Limited Severity: Pharmacoeconomic Evaluation

Background:

Calcipotriol (calcipotriene) is a vitamin-D3 analogue that has recently become available in North America for the treatment of psoriasis.

Objective:

To perform a pharmacoeconomic analysis to determine the cost-effectiveness from a government payer perspective of calcipotriol compared with medium- to high-potency steroids in the management of plaque-type psoriasis of limited severity.

Methods:

A stepwise analysis was performed. Relevant clinical algorithms were developed after a thorough literature review and input from a clinical panel. A meta-analysis of 31 clinical trials was performed to determine efficacy rates. Costs and resource estimates were obtained from formularies, physician responses, and the literature. Utility values (ratings of health states) were obtained through interviews with 30 patients. Three different decision analytic models reflecting different clinical scenarios in psoriasis management were developed. Total expected costs of therapy including drugs, physician visits, and treatment of failures, and the total Quality Adjusted Life Years (QALYs) for each strategy were calculated. Extensive sensitivity analyses were carried out to explore uncertainty in the parameter estimates entered into the models.

Results:

In the comparison of drug acquisition cost and efficacy, the incremental cost per cure was $414 using a 6-week course of calcipotriol compared with betamethasone valerate. The cost-utility analyses demonstrated that when calcipotriol was used as a second-line therapy to betamethasone valerate, it was as cost-effective as, if not more cost-effective than, clobetasol propionate used for 4 to 6 weeks. Also, when calcipotriol was used as a primary therapy in patients who had failed prior therapies, it was an attractive alternate compared to betamethasone dipropionate and fluocinonide.

Conclusion:

Calcipotriol is a relatively new addition to the topical therapies available to treat psoriasis. In general, tolerability and efficacy are similar to those of topical corticosteroids. In the treatment of psoriatic patients with limited plaque disease, calcipotriol, as a second-line treatment to betamethasone valerate, is a cost-effective alternative to medium- to high-potency corticosteroids.

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.

IL-1α, IL-6 and TNF-α in Cutaneous Lesions of Lupus Erythematosus are Inhibited by Topical Application of Calcipotriol

Lupus Erythematosus (LE) is an autoimmune disorder with an unknown etiology and pathogenesis. Skin lesions of LE express several cytokines which correlate to histological findings such as IL-1 and IL-6 which are mediators of epidermal growth and proliferation. Skin lesions of LE are generally treated with immunosuppressive agents such as oral or topically applied corticosteroids. Recently a new drug, calcipotriol, a vitamin D3 analogue has been useful in treatment of psoriasis with no ad verse effect on calcium metabolism. This drug shares immunomodulatory effects with vit. D3 by inhibiting several cytokines produced by keratinocytes.

In order to test the clinical effectiveness of calcipotriol in cutaneous lesions of LE we have investigated several proinflammatory cytokines such as: IL-1α, IL-1β, IL-4, IL-5, IL-6, IL-8, MCP-1, TNF-α. Using an avidin-biotin immunoperoxidase system we have found IL-1 in both forms, IL-6 and TNF-α in basal keratinocytes in patients affected with LE, after treatment they were reverted to normal. This inhibition is induced at a molecular level as demostrated by reduced IL-1, IL-6 and TNFα mRNA expression. This is the first report showing that calcipotriol is effective in cutaneous lesions of LE and suggesting that this action is due to an inhibition of protein synthesis and mRNA expression for IL-1α, IL-6 and TNFα.

The role of vitamin D in psoriasis: a review

BACKGROUND AND OBJECTIVE

Psoriasis is a common, chronic autoimmune inflammatory skin disorder, which has potential systemic complications and is clinically defined by sharply demarcated, erythematous patches and plaques covered by a characteristic silvery white scale. Topical corticosteroids have widely been regarded as the mainstay first line of treatment. Recently, topical vitamin D analogs have been added to the first-line treatment repertoire as well, either as monotherapy or in combination with topical steroids due to synergistic, complementary effectiveness. In this paper, we review the role of vitamin D in the pathophysiology and treatment of psoriasis.

METHODS

A comprehensive search of the Cochrane Library, MEDLINE, and PUBMED databases were performed to identify relevant basic science and clinical trial literature investigating the role of vitamin D in psoriasis. Primary endpoints in clinical trials were largely based on clinical improvement as assessed by the psoriasis area severity index score or physician's global assessment.

RESULTS AND CONCLUSION

The role of vitamin D in psoriasis is complex and extensive. Oral and topical vitamin D therapies provide comparable efficacies to corticosteroids when used as monotherapy and may be superior when used in combination with a potent topical steroid. Additionally topical vitamin D analogs demonstrate a favorable safety profile with "steroid-sparing" effects. Thus, topical vitamin D derivatives should be considered an indispensable component of the current physician's arsenal in the treatment of psoriasis.

Anti-Inflammatory Effects of Tacalcitol (1,24(R)(OH)2D3, TV-02) in the Skin of TPA-Treated Hairless Mice

Tacalcitol (1,24(R)(OH)2D3, TV-02) inhibited the TPA-induced inflammatory cell infiltration (largely neutrophils) histopathologically and myeloperoxidase (MPO) activity dose-dependently. Tacalcitol inhibited the mRNA expression and protein production of TPA-induced macrophage inflammatory protein-2 (MIP-2) and KC, the functional analogue of human interleukin (IL)-8, in the skin. Immunohistochemical staining of the TPA-applied skin revealed that mast cells expressed MIP-2, whereas KC was observed in keratinocytes, fibroblasts and outer root sheath of hair follicles. Furthermore, tacalcitol inhibited TPA-induced mast cell degranulation 24 hr after application without influence on the total number of mast cells. In this study, tacalcitol was found to have an inhibitory effect on cutaneous inflammation such as inhibition of neutrophil infiltration, MIP-2 and KC production, and mast cell degranulation in TPA-treated hairless mice. These results suggest that tacalcitol modulates cutaneous inflammation as well as keratinocyte proliferation and differentiation, and the inhibitory effect of tacalcitol on cutaneous inflammation may contribute to clinical the effectiveness in the treatment of psoriasis.

Topical treatments for chronic plaque psoriasis

BACKGROUND

Chronic plaque psoriasis is the most common type of psoriasis, and it is characterised by redness, thickness, and scaling. First-line management of chronic plaque psoriasis is with topical treatments, including vitamin D analogues, topical corticosteroids, tar-based preparations, dithranol, salicylic acid, and topical retinoids.

OBJECTIVES

To compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis, relative to placebo, and to similarly compare vitamin D analogues (used alone or in combination) with other topical treatments.

SEARCH METHODS

We updated our searches of the following databases to February 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2011, Issue 2), MEDLINE (from 1948), EMBASE (from 1980), Science Citation Index (from 2008), Conference Proceedings Citation Index - Science (from 2008), BIOSIS (from 1993), Dissertation Abstracts via DialogClassic (all publication years), and Inside Conferences (all publication years).We identified ongoing and unpublished studies from the UK Clinical Research Network Study Portfolio and the metaRegister of Controlled Trials. We checked the bibliographies of published studies and reviews for further references to relevant trials, and we contacted trialists and companies for information about newly published studies.A separate search for adverse effects was undertaken in February 2011 using MEDLINE and EMBASE (from 2005).Final update searches for both RCTs and adverse effects were undertaken in August 2012. Although it has not been possible to incorporate RCTs and adverse effects studies identified through these final searches within this review, we will incorporate these into the next update.

SELECTION CRITERIA

Randomised trials comparing active topical treatments against placebo or against vitamin D analogues (used alone or in combination) in people with chronic plaque psoriasis.

DATA COLLECTION AND ANALYSIS

One author extracted study data and assessed study quality. A second author checked these data. We routinely contacted trialists and companies for missing data. We also extracted data on withdrawals and on local and systemic adverse events. We defined long-term trials as those with a duration of at least 24 weeks.

MAIN RESULTS

This update added 48 trials and provided evidence on 7 new active treatments. In total, the review included 177 randomised controlled trials, with 34,808 participants, including 26 trials of scalp psoriasis and 6 trials of inverse psoriasis, facial psoriasis, or both. The number of included studies counted by Review Manager (RevMan) is higher than these figures (190) because we entered each study reporting a placebo and an active comparison into the 'Characteristics of included studies' table as 2 studies.When used on the body, most vitamin D analogues were significantly more effective than placebo, with the standardised mean difference (SMD) ranging from -0.67 (95% CI -1.04 to -0.30; 1 study, 119 participants) for twice-daily becocalcidiol to SMD -1.66 (95% CI -2.66 to -0.67; 1 study, 11 participants) for once-daily paricalcitol. On a 6-point global improvement scale, these effects translate into 0.8 and 1.9 points, respectively. Most corticosteroids also performed better than placebo; potent corticosteroids (SMD -0.89; 95% CI -1.06 to -0.72; I² statistic = 65.1%; 14 studies, 2011 participants) had smaller benefits than very potent corticosteroids (SMD -1.56; 95% CI -1.87 to -1.26); I² statistic = 81.7%; 10 studies, 1264 participants). On a 6-point improvement scale, these benefits equate to 1.0 and 1.8 points, respectively. Dithranol, combined treatment with vitamin D/corticosteroid, and tazarotene all performed significantly better than placebo.Head-to-head comparisons of vitamin D for psoriasis of the body against potent or very potent corticosteroids had mixed findings. For both body and scalp psoriasis, combined treatment with vitamin D and corticosteroid performed significantly better than vitamin D alone or corticosteroid alone. Vitamin D generally performed better than coal tar, but findings relative to dithranol were mixed. When applied to psoriasis of the scalp, vitamin D was significantly less effective than both potent corticosteroids and very potent corticosteroids. Indirect evidence from placebo-controlled trials supported these findings.For both body and scalp psoriasis, potent corticosteroids were less likely than vitamin D to cause local adverse events, such as burning or irritation. Combined treatment with vitamin D/corticosteroid on either the body or the scalp was tolerated as well as potent corticosteroids, and significantly better than vitamin D alone. Only 25 trials assessed clinical cutaneous dermal atrophy; few cases were detected, but trials reported insufficient information to determine whether assessment methods were robust. Clinical measurements of dermal atrophy are insensitive and detect only the most severe cases. No comparison of topical agents found a significant difference in systemic adverse effects.

AUTHORS' CONCLUSIONS

Corticosteroids perform at least as well as vitamin D analogues, and they are associated with a lower incidence of local adverse events. However, for people with chronic plaque psoriasis receiving long-term treatment with corticosteroids, there remains a lack of evidence about the risk of skin dermal atrophy. Further research is required to inform long-term maintenance treatment and provide appropriate safety data.

Comparison of clinical effects of psoriasis treatment regimens among calcipotriol alone, narrowband ultraviolet B phototherapy alone, combination of calcipotriol and narrowband ultraviolet B phototherapy once a week, and combination of calcipotriol and narrowband ultraviolet B phototherapy more than twice a week

We compared the clinical efficacy of various psoriasis treatments among: (i) topical application of calcipotriol ointment twice daily (group I); (ii) topical application of calcipotriol ointment twice daily and narrowband ultraviolet B NB-UVB phototherapy once a week (group II); (iii) topical application of heparinoid ointment twice daily and NB-UVB phototherapy more than twice a week (group III); and (iv) topical application of calcipotriol ointment twice daily and NB-UVB phototherapy more than twice a week (group IV). Ten patients were randomly selected for each group and treated by the indicated regimens for 12 weeks. All treatments were effective and significantly improved Psoriasis Area and Severity Index (PASI) scores, self-administered PASI scores and visual analog scale scores of pruritus. Group IV showed most marked and rapid reduction in PASI and self-PASI scores among the four regimens. Although the serum levels of interleukin (IL)-17, IL-20 and IL-22 and psoriasis disability index were significantly decreased after the treatments, no significant difference was detected among the four groups. Our study indicates that combination of calcipotriol ointment plus NB-UVB more than twice a week is superior to other treatment regimens, rapidly improving psoriasis lesions.

[Hungarian consensus regarding the role of vitamin D in the prevention and treatment of diseases]

The metabolism of vitamin D is unique in the human body and its diverse effects are present in almost every organ. Vitamin D deficiency is one of the most prominent health issues in the civilized world. For the solution of this concern an extensive collaboration is imperative. Recognizing this necessity the most prominent Hungarian medical associations fighting with the effects of vitamin D deficiency worked out a collective consensus on the importance, diagnosis, prevention and suggested therapy of vitamin D deficiency. Along with the clinical guidelines of the different associations, the result of this consensus could serve as guidance for the practicing doctors in the prevention and therapy of vitamin D deficiency. In addition the consensus aims to direct the attention of decision-makers and the general public on the significance of this issue.

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.

A combination therapy of calcipotriol cream and PUVA reduces the UVA dose and improves the response of psoriasis vulgaris

BACKGROUND

The addition of calcipotriol ointment to PUVA therapy for psoriasis vulgaris results in a lower total UVA dose and a faster onset of response. The addition of calcipotriol cream to PUVA, however, has not been studied.

OBJECTIVE

To investigate whether combining calcipotriol cream with PUVA therapy has a UVA sparing effect.

METHODS

We performed a randomized, multicentre, vehicle-controlled, double-blind, 12-week comparative study including 120 patients with psoriasis covering 20-50% body surface area. The study consisted of a washout phase followed by a 10-week treatment phase. PUVA therapy three times weekly was added within 1 week after randomization. Efficacy was assessed by the Psoriasis Area and Severity Index (PASI).

RESULTS

At baseline the mean PASI scores were 17.5 and 19.2 in the calcipotriol and vehicle (placebo) groups, respectively. At the end of treatment, the mean PASI scores were 2.65 and 7.03 (p<0.01), respectively. A reduction in PASI score >90% was observed in 69% of the patients in the calcipotriol-treated group and in 36.4% of the patients in the vehicle group (p<0.01).

CONCLUSION

Calcipotriol cream plus PUVA clearly reduces the cumulative dose of UVA and improves the response of psoriasis vulgaris to PUVA.

Topical treatments for chronic plaque psoriasis

BACKGROUND

Chronic plaque psoriasis is the most common type of psoriasis and is characterised by redness, thickness and scaling. First line management of chronic plaque psoriasis is with topical treatments, including vitamin D analogues, topical corticosteroids, tar-based preparations, dithranol, salicylic acid and topical retinoids.

OBJECTIVES

To compare the effectiveness, tolerability and safety of topical treatments for chronic plaque psoriasis with placebo; to compare vitamin D analogues with other topical treatments.

SEARCH STRATEGY

The Cochrane Skin Group's Trials Register was searched (2004/12). To update an unpublished 2002 review we also searched CENTRAL in The Cochrane Library (Issue 1,2005); MEDLINE (to 2005/02); EMBASE (to 2005/08); Science Citation Index (to 2005); Biosis (to 2005); Dissertation Abstracts (all publication years); Inside Conferences (all publication years); SIGLE (to 2005); National Research Register (all projects with a start date of 2001 to 2005); metaRegister of Current Controlled Trials.

SELECTION CRITERIA

Randomised trials comparing treatments against placebo or against vitamin D analogues in people with chronic plaque psoriasis.

DATA COLLECTION AND ANALYSIS

One author extracted study data and assessed study quality. A second author checked these data. We routinely contacted triallists and companies for missing data. We extracted data on withdrawals and adverse events.

MAIN RESULTS

The review included 131 RCTs with 21,448 participants. Vitamin D was significantly more effective than placebo, although there was a wide variation in effect size with the standardised mean difference (SMD) ranging from -0.82 (95% CI -1.34 to -0.29) to -1.90 (95% CI -2.09 to -1.71). With one exception, all corticosteroids performed better than placebo, with potent corticosteroids (SMD: -0.95 (95% CI: -1.11 to -0.80; I(2): 61.1%; 17 studies; 2386 participants)) having smaller benefits than very potent corticosteroids (SMD: -1.29 (95% CI: -1.45 to -1.13; I(2): 53.2%; 11 studies; 1571 participants)). Dithranol and tazarotene performed better than placebo. Head-to-head comparisons of vitamin D against potent or very potent corticosteroids found no significant differences. However, combined treatment with vitamin D /corticosteroid performed significantly better than either vitamin D alone or corticosteroid alone. Vitamin D performed better than coal tar, but findings relative to dithranol were mixed. Potent corticosteroids were less likely than vitamin D to cause local adverse events. No comparison of topical agents found a significant difference in systemic adverse effects.

AUTHORS' CONCLUSIONS

Corticosteroids perform as well as vitamin D analogues and are associated with a lower incidence of local adverse events. Further research is required to inform long-term maintenance treatment.

Topical becocalcidiol for the treatment of psoriasis vulgaris: a randomized, placebo-controlled, double-blind, multicentre study

BACKGROUND

Becocalcidiol is a vitamin D(3) analogue which has not caused hypercalcaemia or significant irritation in preclinical trials.

OBJECTIVES

To evaluate the efficacy and safety of two dosing regimens of becocalcidiol ointment (low dose = 75 microg g(-1) once daily for 8 weeks; high dose = 75 microg g(-1) twice daily for 8 weeks) in the treatment of plaque-type psoriasis.

METHODS

One hundred and eighty-five subjects with chronic plaque-type psoriasis affecting 2-10% of their body surface area took part in a multicentre, double-blind, parallel-group, vehicle-controlled, randomized controlled trial comparing topical application of placebo, becocalcidiol 75 microg g(-1) once daily (low dose) or becocalcidiol twice daily (high dose) for 8 weeks. Main outcomes included Physician's Static Global Assessment of Overall Lesion Severity (PGA) score; Psoriasis Symptom Severity (PSS) score; adverse events; and laboratory assessment.

RESULTS

In the intent-to-treat population at week 8, high-dose becocalcidiol was statistically superior to vehicle [P = 0.002; 95% confidence interval (CI) 6.7-32.2], with 16 of 61 (26%) subjects achieving a PGA score of clear or almost clear. Greater improvement in PSS score was seen with high-dose becocalcidiol than with vehicle, but this result did not quite achieve statistical significance (P = 0.052; 95% CI -16.2 to 0.1). In all groups, therapy was safe and well tolerated, with fewer subjects experiencing irritation than is reported in studies using calcipotriol.

CONCLUSIONS

Treatment with high-dose topical becocalcidiol for 8 weeks led to almost or complete clearing of moderate plaque-type psoriasis in over a quarter of patients. Therapy was safe and well tolerated.

The treatment of psoriasis vulgaris: 1% topical methotrexate gel

BACKGROUND

In general, 70% of patients with psoriasis prefer topical therapy as the treatment of choice.

AIM

To evaluate the efficacy and tolerability of 1% topical methotrexate gel vs. placebo (vaseline ointment) as treatment for psoriasis.

METHODS

Forty patients (20 females and 20 males) with chronic plaque-type psoriasis joined the study. Each patient was allocated to apply 1% methotrexate gel and placebo topically to their two target lesions, equal in area and disease severity, twice daily for 8 weeks. Lesions were scored at baseline and after 2, 4, 6, and 8 weeks of treatment for erythema, scale, and infiltration. The global improvement and histopathologic features were also assessed after methotrexate treatment.

RESULTS

At the end of treatment, erythema was cleared totally in 47.5% of patients treated with methotrexate vs. 7.5% of those treated with placebo, and infiltration in 22% of patients treated with methotrexate vs. 2.5% of those treated with placebo (P<0.01). Clinical improvement was almost the same for the two groups with regard to scale (P<0.5). The global improvement was 97% for patients treated with methotrexate vs. 60% for those treated with placebo, and a significant difference was found between the groups (P<0.01). Histopathologic improvement was achieved in the methotrexate group (P<0.01). No side-effects were observed.

CONCLUSION

The findings of this study suggest that methotrexate 1% in a hydrophilic gel is well tolerated and significantly more effective than placebo as a topical medication for the treatment of psoriasis vulgaris.