Calcipotriol Plus Betamethasone Dipropionate Aerosol Foam For Scalp Psoriasis

A narrative review of fixed combination calcipotriol/betamethasone aerosol foam (Enstilar®) in the management of psoriasis with scalp involvement

The scalp is the most common site affected in patients with psoriasis with up to 80% of these patients having some degree of scalp involvement. In this narrative review, we evaluate available data on the use of an innovative aerosol foam formulation of calcipotriol plus betamethasone dipropionate (Cal/BD) to treat patients with psoriasis and scalp involvement. The full PubMed database was searched using the terms "calcipotriol", "betamethasone dipropionate" and "aerosol foam", and all articles relating to "psoriasis with scalp involvement" were retrieved and used in the preparation of this review. The evidence supporting the clinical effectiveness, tolerability and impact on health outcomes of Cal/BD aerosol foam in patients with scalp psoriasis was obtained from a phase II clinical trial and real-world evidence data from a non-interventional study as well as from two case series. The findings from these studies show that Cal/BD aerosol foam is rapidly effective, improves skin condition, alleviates symptoms such as itch, and has a positive impact on patient quality of life. These attributes address several unmet needs for patients with psoriasis with scalp involvement and have the potential to improve individual adherence to treatment.

Topical foam as a promising carrier system for active pharmaceutical ingredients: review of clinical studies

Skin disorders are preferentially treated by topical administration of medicines or cosmetics because of the possibility of local action. However, a great concern is the delivery of topical actives with effective penetration through the stratum corneum to ensure the desired effect. Considering the search for a carrier system that allows the penetration/permeation of active pharmaceutical ingredients through this structure, searching for effective topical pharmaceutical forms is needed. Foams have been widely studied over the years due to their high capacity to favor the active to overcome the cutaneous barrier and because this form of presentation has ease of application and high acceptability by users. The objective of this review was to analyze the potential of foam as a topical pharmaceutical form for treating skin disorders, upon clinical cases reported in the literature. Foam presents technical advantages when compared to other conventional topical pharmaceutical forms due to its fast action, high tolerance, and safety, with reduction or total remission of adverse events. Regarding the patient, foam increased the rate of adherence to the treatment. Therefore, it is concluded that foam is an effective, secure, and stable topical presentation form for carrying active pharmaceutical ingredients and widely accepted by patients.

Efficacy of Calcipotriol/Betamethasone Dipropionate Fixed-Combination Aerosol Foam in the Treatment of Localized Scalp Psoriasis: A Real-Life Case Series from Switzerland

Introduction

Scalp psoriasis is one of the most common and challenging manifestations of plaque psoriasis for general practitioners, dermatologists, and patients, as successful topical management requires the choice of effective ingredients, an appropriate formulation, and clear application instructions to patients. To date, only limited experience is available for the calcipotriol (50 μg/g)/betamethasone dipropionate (0.5 mg/g) aerosol foam formulation (Cal/BD foam) in the treatment of scalp psoriasis.

Methods

In this Swiss real-world patient case series, we asked 10 consecutive patients with active scalp psoriasis to apply the Cal/BD foam once daily before bedtime for a period of 4 weeks. Clear application and rinse-off instructions were provided.

Results

A total of 10 consecutive adult patients were treated between April and May 2019. Two patients suffered from mild, five from moderate, and three from severe scalp psoriasis. In eight out of the 10 patients, scalp psoriasis was the only manifestation of disease. All patients had received previous topical treatments, mainly topical corticosteroids (TCS), tar shampoo, and salicylic acid. After 4 weeks of treatment with Cal/BD foam, the scalp psoriasis improved in all 10 patients by ≥ 2 points on a 5-point severity assessment scale. Eight out of 10 patients achieved clear/almost clear skin after 4 weeks of treatment, with no further keratolytic treatments needed. Adverse events were not observed in any of the patients. Overall, patients were very satisfied with the ease of use, the efficacy, and the safety of the Cal/BD foam.

Conclusion

Our case series confirms that Cal/BD foam is a rapid, effective, and convenient treatment for localized scalp psoriasis in a nonselected real-world patient cohort refractory to TCS or other local treatments. Clear application instructions are crucial for treatment success and cosmetic acceptance, however.

Long-term maintenance treatment of psoriasis: the role of calcipotriol/betamethasone dipropionate aerosol foam in clinical practice

Most patients with psoriasis present with localized mild-to-moderate disease. In this case, the application of topical treatments in the first-line setting is recommended in most cases.Among different topical options, the fixed-dose combination of betamethasone dipropionate (BD) and vitamin D analogue (Cal) aerosol foam (Enstilar®, Leo Pharma) is approved as first-line topical therapy for the treatment of psoriasis in USA and the EU, due to its high efficacy and its favorable administration scheme.The PSO-LONG was the first trial to report on the long-term efficacy and safety of the Cal/DB foam treatment for the proactive management of psoriasis and now, the indications of Cal/BD foam included its use in the psoriasis maintenance treatment. However, the precise role of this treatment and the potential therapeutic schemes in the long-term management of psoriasis need further clarification.This Position Paper, authored by a group of Italian Expert Dermatologists, critically discusses the long-term management of psoriasis with Cal/BD foam in clinical practice. In particular, the biological rationale in the proactive treatment with Cal/BD foam and current evidence regarding this therapeutic approach are presented, along with its application also in patients with moderate-to-severe disease, difficult-to-treat lesions, or within combination regimens. In addition, strategies to improve adherence to long-term treatment of psoriasis are discussed.

Patient satisfaction with calcipotriol/betamethasone dipropionate cutaneous foam for the treatment of plaque psoriasis: The LION real-life multicenter prospective observational cohort study

Topical treatment is the mainstay for mild or moderate psoriasis, but patients are generally little satisfied. Calcipotriol/betamethasone dipropionate (Cal/BD) cutaneous foam has shown to improve signs and symptoms in plaque psoriasis patients. This study assessed patient's satisfaction with Cal/BD foam in a real‐life Italian dermatological clinical practice. A multicenter, 4‐week observational prospective cohort study enrolled, in 17 Italian dermatology clinics, adult patients with plaque psoriasis on the body and/or scalp. Treatment satisfaction was assessed by 9‐item Treatment Satisfaction Questionnaire for Medication (TSQM‐9), preference over previous treatments by Patient Preference Questionnaire (PPQ), and change in disease state by Psoriasis Area Severity Index (PASI). Overall 256 patients were eligible, with a mean (SD) age of 55.6 (15.4) years, 59.4% were males. Psoriasis severity was mild in 52.0% of patients, moderate in 43.3%, and severe in 4.7%. Scalp involvement was present in 36.7% of patients. Previous antipsoriatic treatments had been received by 80.5% of patients. TSQM‐9 median (25th–75th percentile) scores were 83.3 (66.7–88.9) for effectiveness, 77.8 (66.7–88.9) for convenience, and 78.6 (64.3–92.9) for global satisfaction. Mean (SD) PASI value decreased from 7.3 (4.8) to 2.1 (2.7) after 4 weeks. More than 90% of patients previously treated for psoriasis evaluated the Cal/BD foam more effective, easier to use and better tolerated compared to previous topical treatments at PPQ. This observational study provides real‐life evidence of a high level of satisfaction with effectiveness and convenience of the Cal/BD foam in a cohort of plaque psoriasis patients, with an objective improvement in PASI.

Topical Treatment of Psoriasis Vulgaris: The Swiss Treatment Pathway

Topical treatment is crucial for the successful management of plaque psoriasis. Topicals are used either as a stand-alone therapy for mild psoriasis or else in combination with UV or systemic treatment for moderate-to-severe disease. For the choice of a suitable topical treatment, the formulation matters and not just the active substances. This expert opinion paper was developed via a non-structured consensus process by Swiss dermatologists in hospitals and private practices to illustrate the current treatment options to general practitioners and dermatologists in Switzerland. Defining treatment goals together with the patient is crucial and increases treatment adherence. Patients' personal preferences and pre-existing experiences should be considered and their satisfaction with treatment and outcome regularly assessed. During the induction phase of "classical" mild-to-moderate psoriasis, the fixed combination of topical calcipotriol (Cal) 50 μg/g and betamethasone dipropionate (BD) 0.5 mg/g once daily is frequently used for 4-8 weeks. During the maintenance phase, a twice weekly (proactive) management has proved to reduce the risk of relapse. Of the fixed combinations, Cal/BD aerosol foam is the most effective formulation. However, the individual choice of formulation should be based on a patient's preference and the location of the psoriatic plaques. Tailored recommendations are given for the topical management of specific areas (scalp, facial, intertriginous/genital, or palmoplantar lesions), certain symptoms (hyperkeratotic or hyperinflammatory forms) as well as during pregnancy or a period of breastfeeding. As concomitant basic therapy, several emollients are recommended. If topical treatment alone does not appear to be sufficient, the regimen should be escalated according to the Swiss S1-guideline for the systemic treatment of psoriasis.

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.