Superiority of ivermectin 1% cream over metronidazole 0·75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial

BACKGROUND

Few therapeutic alternatives currently exist in the treatment of papulopustular rosacea (PPR).

OBJECTIVES

To demonstrate superiority of once-daily ivermectin 1% cream (IVM 1%) once daily vs. twice-daily metronidazole (MTZ 0·75%) cream, regarding percentage reduction of inflammatory lesions in subjects with moderate to severe PPR.

METHODS

In this Phase 3, investigator-blinded, randomized, parallel-group study, subjects received IVM 1% once daily, or MTZ 0·75% twice daily over 16 weeks. Efficacy assessments were inflammatory lesion counts and Investigator's Global Assessment (IGA). Safety assessments included incidence of adverse events (AEs) and local tolerance parameters. Subjects evaluated their disease following a 5-grade scale and completed questionnaires.

RESULTS

A total of 962 subjects were randomized to receive IVM 1% (n = 478) or MTZ 0·75% (n = 484). At week 16, IVM 1% was significantly superior to MTZ 0·75% in terms of reduction from baseline in inflammatory lesions (83·0% vs. 73·7%; P < 0.001), observed as early as week 3 (Last Observation Carried Forward, LOCF). IGA results (subjects 'clear' or 'almost clear') also favoured IVM 1%: 84·9% vs. 75·4%, respectively (P < 0.001). Incidence of AEs was comparable between groups and local tolerability was better for IVM 1%. More subjects receiving IVM rated their global improvement as 'excellent' or 'good.'

CONCLUSIONS

Ivermectin 1% cream was significantly superior to MTZ 0·75% cream and achieved high patient satisfaction.

Development and psychometric validation of the REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) questionnaire: a common measure of plaque-type psoriasis severity and treatment efficacy for patients and clinicians

Background

To date, there is no global consensus on the definition of the severity of psoriasis. The REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) questionnaire has recently been developed to provide a better understanding of plaque-type psoriasis severity and treatment efficacy from both patient and clinician perspectives.

Objective

This study aimed to develop and psychometrically validate the new REFLETS questionnaire to evaluate patient and clinician perceptions of plaque-type psoriasis severity and treatment efficacy.

Methods

Two similar versions of the REFLETS questionnaire were developed following a rigorous methodology for clinicians and patients, referring to ‘the psoriasis of your patient' or to ‘your psoriasis’, respectively. An observational, longitudinal, multicentre study was conducted in France with 34 dermatologists and 430 mild to severe plaque-type psoriasis patients to finalize the questionnaire and evaluate its psychometric properties.

Results

Two dimensions were defined – severity and treatment efficacy – with three subdimensions within severity (impact of psoriasis, symptoms and disease course), and two individual items on joint pain. The questionnaire was well accepted by clinicians and patients. Excellent internal consistency (Cronbach's alpha = 0.66–0.98) and test–retest reliability (intraclass correlation coefficients = 0.83–0.94) were demonstrated. REFLETS scores were moderately to highly correlated to Psoriasis Area and Severity Index (r = 0.35–0.70), Skindex-29 (r = 0.46–0.82) and DLQI scores (r = 0.36–0.82). Patients with decreased psoriasis severity and those with increased treatment efficacy, according to patient global evaluations, had lower severity and higher treatment efficacy REFLETS scores, respectively.

Conclusion

REFlective evaLuation of psoriasis Efficacy of Treatment and Severity is a promising tool for assessing plaque-type psoriasis severity and treatment efficacy from patient and clinician perspectives. It may help to improve patient and clinician communication in treatment decision making.

Impact of systemic treatment of psoriasis on inflammatory parameters and markers of comorbidities and cardiovascular risk: results of a prospective longitudinal observational study

BACKGROUND

Several markers of comorbidities and cardiovascular (CV) risk are disturbed in moderate to severe psoriasis (PsO). The effect of systemic treatments of psoriasis on these markers remains poorly understood.

OBJECTIVES

To study the frequency of disturbance of inflammatory parameters and markers of comorbidities and CV risk associated with moderate to severe PsO and psoriatic arthritis (PsA), and to assess their evolution under systemic treatments.

METHODS

Monocentric prospective study on patients with PsO and PsA starting a systemic treatment for their psoriasis. The following markers were evaluated at baseline (M0), 3 months (M3) and 6 months (M6); weight, fasting blood glucose, blood pressure, uric acid, hepatic steatosis, smoking, lipid, metabolic and inflammatory parameters.

RESULTS

Forty-three patients, 31 PsO and 12 PsA, were included. Forty completed the study. Response to treatment was good, with 71% of the population obtaining a Psoriasis Area and Severity Index (PASI) of 75. All patients had at least one comorbidity, and 45% had two or more. A statistically significant decrease was observed only for inflammatory parameters (C-reactive protein [CRP], P = 0.004) and erythrocyte sedimentation rate (ESR, P = 0.002). We did not observe any correlation between the PASI and CRP (correlation coefficient 0.128, P = 0.438) or ESR (correlation coefficient 0.294, P = 0.069) for responding patients.

CONCLUSIONS

We observed a high frequency of disturbance of inflammatory parameters and markers of comorbidities and CV risk in a population with moderate to severe PsO and PsA, most of which were not detected before. A significant decrease in inflammatory parameters was noted after the introduction of systemic therapy, while other parameters remained unaffected by the treatment, except the weight that increased under biologics therapies.

Laser-assisted depigmentation for resistant vitiligo: a retrospective case series with long-term follow-up

BACKGROUND

Blanching creams are used to depigment and to achieve uniform skin tone in widespread vitiligo. Length of the treatment and side-effects strongly limit their use in common practice.

OBJECTIVES

To assess the long-term efficacy and tolerance of Q-Switched (QS) lasers for depigmenting the remaining unaffected skin in vitiligo.

METHODS

Retrospective study of vitiligo patients treated with QS lasers in the Department of Dermatology of the University Hospital of Nice, France, from 2002 to 2011. Localizations and the percentage of body surface area of treated lesions, the total number of sessions and the possible relapses and side-effects, were analysed. Global satisfaction of the patients was evaluated on a visual analogical scale.

RESULTS

Sixteen areas of normally pigmented skin were treated in six patients. The median number of sessions to achieve a complete depigmentation was 2 (1-6). The mean duration of follow-up was 36 months (19-120). One third of the patients had no relapse. A complete repigmentation was observed after 21 months in one patient; a 50% repigmentation was noted in one patient, 7 months after the end of the treatment. Two patients showed a minimal repigmentation (<25%), 18 months and 9 years after the first laser treatments. The repigmentations were effectively treated with a maintenance session. The mean total number of sessions performed during this period was 3 (1-20). Side-effects were limited to transient purpura and crusts. The satisfaction of the patients was excellent (mean 9/10). conclusions: QS lasers appear as an efficient and safe modality for depigmenting normal skin in vitiligo.

Topical corticosteroids in plaque psoriasis: a systematic review of efficacy and treatment modalities

INTRODUCTION

Topical steroids are used for more than 50 years to treat mild-to-moderate plaque psoriasis. The purpose of this systematic review was to evaluate the efficacy but also the optimal modalities of administration of topical corticosteroids in psoriasis i.e. influence of steroid potency on clinical response, putative impact of topical formulation, occlusion procedure, rate of application to control the initial response and the potential interest of a maintenance treatment to prolong psoriasis clearance.

MATERIAL AND METHODS

A systematic search was performed between 1980 and January 2011 in Medline, Embase and Cochrane databases (English and French language, adults), using the keywords 'psoriasis'/exp/mj AND 'corticosteroid'/exp/mj. To analyse response across studies, three levels of response were categorized depending on the data available in studies: percentage of patients who achieved more than 50%, 75% or 90% improvement of initial psoriasis severity.

RESULTS

From an initial selection of 1269 references, 1166 references were excluded on reading the title or the abstract and 32 on reading the article and 71 were finally retained and analysed. Fifty randomized controlled trials (RCT) assessing topical steroids in the initial treatment of mild-to-severe psoriasis body plaque psoriasis were retained: 40 were parallel-group studies and 10 were within-patient studies. Treatment duration was mostly 4 weeks. Sample size varied from 30 to 1 603 patients. Outcome measures to assess efficacy were highly variable. A total of 30-90% patients across parallel group studies experienced more than 50% of initial mild-to-severe psoriasis improvement while from 7% to 85% experienced more than 75% improvement and from 5% to 85% experienced at least 90% of improvement. The success rate in the within-patient studies varied from 10% to 70%. Eighteen RCT were performed in scalp psoriasis: 16 were parallel-group and two were within-patient studies, with a treatment follow-up time from 2 weeks to 6 months, enrolling 42-1417 patients. A total from 40% to 75% patients across studies experienced more than 75% of initial scalp psoriasis improvement and from 43% to 90% experienced more than 90% initial psoriasis improvement. Only three RCT studies evaluated topical steroids as a maintenance treatment for body psoriasis and one for scalp lesions. Despite heterogeneity in treatment schedule, topical steroid intermittent maintenance treatment was shown to prolong remission. The literature analysis did not provide with high evidence-based quality data on the role of formulation, topical steroid potency, number of applications per day to obtain the highest rate of success excepting occlusion dressing which provided with additional benefit.

CONCLUSION

The clinical development of topical steroids in psoriasis did not follow state of the art modern methodology. Treatment success appears to be highly variable across studies. Maintenance intermittent treatment appears to be useful to prolong remission. Recommendations concerning topical steroids treatment modalities in plaque psoriasis should be mostly based on expert opinion.

Topical corticosteroids in plaque psoriasis: a systematic review of risk of adrenal axis suppression and skin atrophy

BACKGROUND

Topical steroids have been used for more than 50 years in mild-to-moderate plaque psoriasis and carry a theoretical risk of adverse events.

OBJECTIVES

The aim of this systematic literature review was to evaluate the risk of hypothalamo-pituitary-adrenal (HPA) axis suppression and the risk of skin atrophy with topical steroids in the treatment of plaque psoriasis.

METHODS

A systematic search between 1980 and January 2011 in Medline, Embase and Cochrane databases (English, French language, adults), using the keywords 'psoriasis'/exp/mj AND 'corticosteroid'/exp/mj,

RESULTS

Altogether 1269 references were found. Of these 1124 articles were excluded by reading the abstract and 123 by reading the article. A total of 22 randomized trials were selected. Effects on HPA axis: Thirteen studies, with a sample size varying from 7 to 341 patients, were selected. The effect on HPA axis was evaluated by the morning cortisol level (11 studies), the 24 h urine steroid levels (five studies) and/or by the Synacthen test (three studies). Reduction of morning cortisol was observed in 0-25% of patients in 10 short-term studies (two in scalp psoriasis, eight in body psoriasis) and in 48% of patients in the remaining short-term study (body psoriasis). Only four of these studies with three on body psoriasis evaluated the effect of long-term treatment defined as 6-month treatment duration or longer and did not identify HPA axis suppression by cortisol level measurement. The Synacthen test, considered as the gold standard to assess HPA axis, was always normal. There was no evidence of clinically significant HPA axis suppression due to absorption of topical steroids even when treating the scalp or in patients with extensive disease. Risk of skin atrophy: Thirteen studies with topical steroid evaluating treatment durations from 4 weeks to 1 year were analysed. The frequency of skin atrophy assessed clinically, varied from 0% to 5% of patients.

CONCLUSIONS

The literature analysis on topical steroids in psoriasis is reassuring although the quality of safety studies is limited with a majority of short-term studies. Although short-term biological effects of topical steroids on the HPA axis were observed in several clinical studies, they were not associated with clinical signs. Adequately designed long-term studies would be necessary to better determine the risk of skin atrophy using modern methods of evaluation such as dermoscopy and echography.

Evaluation of the efficacy and safety of a CS20® protective barrier gel containing OGT compared with topical aciclovir and placebo on functional and objective symptoms of labial herpes recurrences: a randomized clinical trial

BACKGROUND

Topical or systemic antiviral drugs reduce the duration of herpes simplex virus 1 (HSV-1) recurrences but may not alleviate functional symptoms.

OBJECTIVES

To assess the efficacy and safety of CS20 (Acura 24(®) ) protective barrier gel versus topical aciclovir and placebo in resolving functional symptoms in HSV-1 labial recurrences.

METHODS

A prospective, randomized, single-centre, assessor-blinded study of CS20 versus topical aciclovir or placebo. The primary endpoint was the total score of four herpes-related functional symptoms (pain, burning, itching, and tingling sensations), evaluated by visual analogue scale (VAS). Secondary endpoints encompassed objective skin changes (oedema, crusting and erythema), evaluated by specific clinical scores.

RESULTS

In a study of 106 patients, compared with placebo, a significant improvement in total functional symptom score was observed after 1 day of treatment in the CS20 group, but only after 7 days of treatment in the topical aciclovir group. Burning sensations were significantly reduced by CS20 compared with aciclovir (Days 1-2) or placebo (Days 1-7). Compared to placebo, CS20 significantly reduced pain intensity on Days 1-6. CS20 induced significant and early improvements in the clinical scores for oedema and crusting compared with placebo. Time to cure was similar for CS20 and aciclovir. The treatments were well tolerated and adverse events were comparable in the three treatment groups. Limitations  The single-centre and single-blind design of the study and the preselection of patients.

CONCLUSION

CS20 showed superior effectiveness against functional symptoms (pain and burning) associated with HSV-1 labial recurrences and was similar to aciclovir for time to cure.

Importance of treatment of skin xerosis in diabetes

BACKGROUND

Cutaneous complications are common in diabetes patients and previous studies have shown that diabetes can affect some biophysical skin characteristics. However, the interest of emollients in diabetes has never been clearly demonstrated; i.e. whether they are able to limit skin complications in diabetes patients.

OBJECTIVE

The aim of this study was to evaluate the tolerance and the effect of an emollient on patient with diabetes.

METHOD

Forty patients with diabetes applied the emollient twice daily for 1 month on one arm and one leg, in normal conditions.

RESULTS

A 1-month treatment with an emollient allows a similar skin hydration rate in diabetics to that in healthy people. This dry skin improvement is accompanied by a significant reduction in pruritus and desquamation, and a significant improvement in the skin barrier function.

CONCLUSION

Emollient treatment can be useful in the management of diabetes by limiting skin complications associated with elevated blood sugar.

Epidermolysis bullosa simplex with muscular dystrophy

Epidermolysis bullosa simplex (EBS) is an inherited skin disorder characterized by separation of the epidermis from the underlying dermis, with the cleavage plane lying within the basal-cell layer of the epithelium. The major clinical subtypes of EBS have a dominant inheritance and have been associated with genetic defects in specific domains of keratins K5 and K14 that result in abnormal organization of the keratin network and cell disruption. Autosomal recessive forms of EBS associated with extracutaneous manifestations, such as muscular dystrophy (MIM 226670) or pyloric atresia (MIM 612138), have been linked to genetic mutations in the gene for plectin (PLEC). PLEC mutations have also been found in 2 families with the rare dominant Ogna form of EBS. This article reviews current knowledge on EBS.

Development and validation of nail psoriasis quality of life scale (NPQ10)

BACKGROUND

The chronic and treatment-resistant nature of nail psoriasis affects patients' lives not only physically but also psychologically. Although there are scoring systems available for disease severity, there is as yet no scale to evaluate the impact of this condition upon the patients' quality of life.

OBJECTIVES

This study aims to develop and validate a quality of life scale specifically for nail psoriasis.

METHODS

A questionnaire was developed during a study conducted in France between 2004 and 2005. With the cooperation of l'Association Pour la Lutte Contre le Psoriasis, the questionnaire was sent to a random sample of 4000 of its 17,000 members.

RESULTS

The response rate was 33%. Of the 1309 questionnaires returned, 795 showed the presence of nail psoriasis and these were eligible. The scale score is obtained by adding together the responses to the 10 questionnaire items and the result is expressed as a percentage. The value of the score obtained is proportional to the functional difficulty experienced. The determination of Cronbach's a coefficient and a Principal Component Factor Analysis show, respectively, very good internal consistency and the unidimensional nature of the scale. Test-retest results on 15 patients showed good reproducibility. Results were validated with reference to the Dermatology Life Quality Index. In this study, the NPQ10 score is significantly influenced by gender (women have a higher score) and by the duration of psoriasis (recent onset implies greater functional difficulty). Finally, the score is much higher when the nail psoriasis affects both the hands and the feet.

CONCLUSION

This study confirms a change in the quality of life of patients who have nail psoriasis. The NPQ10 scale, specific to this condition, is simple to use and has the attributes needed in a quality of life scale. The scale must now be tested in longitudinal studies (such as clinical trials) to confirm its ability to measure a change in status.

Psoriasis: an epidemiological evaluation of disease burden in 590 patients

BACKGROUND

There are limited data available on the economical burden of psoriasis and its impact on everyday life.

OBJECTIVE

The aim of this study was to evaluate the impact of psoriasis on personal and professional life, and to evaluate the cost of psoriasis for the patient.

METHODS

We performed a cross-sectional study in psoriasis patients. All patients aged >or=18 years with a diagnosis of plaque-psoriasis confirmed by a physician were included. A self-administered questionnaire evaluating everyday life was constructed with members of the French association of psoriasis patients. In addition, the Dermatology Life Quality Index (DLQI), Working Productivity and Activity Impairment and individual costs were assessed.

RESULTS

A total of 590 patients completed the study. Mean age of the responders was 56 years. The mean DLQI score was 8.5 for patients with severe psoriasis vs. 6.4 for mild psoriasis. Global loss of productivity was 10.7% without significant difference according to the disease severity. Daily activities alteration was most important in patients with severe psoriasis. In this study, 36.8% of patients with severe psoriasis reported a negative impact on their professional life vs. 19.6% for patients with mild psoriasis (P = 0.002). Time devoted to phototherapy was on average 33 h/year/patient and the application of emollients took 25 h/year/patient; 47.3% of patients had a feeling to clean the house more often, in correlation with the severity of the disease. Mean out-of-pocket expenses for the disease was estimated to be 543 euro/year/patient. High impact of psoriasis on quality of life (DLQI >10), age <40 years and joint involvement were significantly associated with an increased risk of loss of work productivity.

CONCLUSION

Psoriasis, particularly severe psoriasis, is a true burden for patients and impacts significantly everyday life and patient's economical resources.

Melasma in Latin America: options for therapy and treatment algorithm

OBJECTIVE/AIM

To examine approaches to therapy for melasma in Latin Americans and to propose treatment algorithms for patients with mild, moderate and severe melasma.

BACKGROUND

Melasma is prevalent in up to 10% of the Latin American population. It is found in all racial groups and is more common in subjects with darker skin phototypes. A number of topical treatments and procedures have been used for melasma. Topical treatments containing hydroquinone are the most popular. Care must be taken when treating melasma to avoid inducing post-inflammatory hyperpigmentation and ochronosis. Determination of the severity of melasma (using the Melasma Area Severity Index and/or Physician's Global Assessment) and choice of the most effective and suitable treatment and/or procedure for individual patients is therefore essential. Sun protection is mandatory for all melasma patients.

METHODS

Thirty-one clinical studies of topical treatments, chemical peels and laser and other therapies used for treating melasma were assessed for the level and quality of clinical evidence, by the Latin American Pigmentary Disorders Academy. The results of this analysis were combined with differential diagnosis guidelines and methods for assessing treatment success to establish algorithms for treating mild and moderate-to-severe melasma.

RESULTS

The most appropriate first-line treatment for mild melasma is hydroquinone 4%, triple combination cream containing hydroquinone 4%, tretinoin 0.05% and fluocinolone acetate 0.01%, double combination (e.g. 4% hydroquinone and 0.1% tretinoin) or non-phenolic therapy where there is an allergy to compounds. In moderate-to-severe melasma, triple combination cream is the recommended first-line treatment. Second-line treatment is double combination or hydroquinone 4% where triple therapy is not available or if allergic to compounds. Sun avoidance measures and broad spectrum sunscreens with high SPF are fundamental for the successful management of the disease.

What are melanocytes really doing all day long...?

Everyone knows and seems to agree that melanocytes are there to generate melanin - an intriguing, but underestimated multipurpose molecule that is capable of doing far more than providing pigment and UV protection to skin (1). What about the cell that generates melanin, then? Is this dendritic, neural crest-derived cell still serving useful (or even important) functions when no-one looks at the pigmentation of our skin and its appendages and when there is essentially no UV exposure? In other words, what do epidermal and hair follicle melanocytes do in their spare time - at night, under your bedcover? How much of the full portfolio of physiological melanocyte functions in mammalian skin has really been elucidated already? Does the presence or absence of melanocytes matter for normal epidermal and/or hair follicle functions (beyond pigmentation and UV protection), and for skin immune responses? Do melanocytes even deserve as much credit for UV protection as conventional wisdom attributes to them? In which interactions do these promiscuous cells engage with their immediate epithelial environment and who is controlling whom? What lessons might be distilled from looking at lower vertebrate melanophores and at extracutaneous melanocytes in the endeavour to reveal the 'secret identity' of melanocytes? The current Controversies feature explores these far too infrequently posed, biologically and clinically important questions. Complementing a companion viewpoint essay on malignant melanocytes (2), this critical re-examination of melanocyte biology provides a cornucopia of old, but under-appreciated concepts and novel ideas on the slowly emerging complexity of physiological melanocyte functions, and delineates important, thought-provoking questions that remain to be definitively answered by future research.

Involvement of FKHRL1 in melanoma cell survival and death

Melanoma is a highly aggressive tumour characterized by a strong resistance to apoptotic stimuli that give rise to a selective advantage for tumour progression and metastasis formation. Therefore, it is of paramount importance to better understand the mechanisms involved in this resistance to apoptosis. In this report, we focused our attention on FKHRL1, a member of the forkhead family of transcription factors, which controls expression of genes involved in cell cycle progression and apoptosis. In melanoma cells, we show that IGF1, which exerts pro-survival properties, induces the phosphorylation and nuclear exclusion of FKHRL1 in a PI3K/AKT-dependent pathway. Moreover, we observe that over-expression of a non-phosphorylable mutant of FKHRL1 (FKHRL1-TM), constitutively localized to the nucleus, promotes apoptotic cell death of melanoma cells. Finally, we find that FKHRL1-TM decreases the expression of survivin, a member of the inhibitor of apoptosis protein and that survivin re-expression partially rescues the deleterious effects of FKHRL1. Taken together, these findings reveal, in melanoma cells, that endogenous FKHRL1 is a downstream target of the PI3K/AKT pathway and suggest that the phosphorylation of this transcription factor may be involved in the pro-survival effects of growth factors such as IGF1. On the other hand, forced nuclear localization of FKHRL1 decreases melanoma cell growth and may serve as a therapeutic strategy against melanoma.

Quality of life in adults with chronic idiopathic urticaria receiving desloratadine: a randomized, double-blind, multicentre, placebo-controlled study

OBJECTIVE

To assess the effect of desloratadine on quality of life (QoL) in chronic idiopathic urticaria (CIU).

STUDY POPULATION

Patients with a history of CIU (pruritus and weals lasting = 6 weeks) were included in this multicentre, randomized, double-blind placebo-controlled study that took place in dermatology centres throughout France. During the study, patients were randomized to receive desloratadine 5 mg daily or placebo for 42 days.

MAIN OUTCOME MEASURES

Variation of the scores of two QoL dermatology-specific tools between baseline and day 42, the French translation version of the Dermatology Life Quality Index (DLQI) and the VQ-Dermato (a French-language scoring instrument).

RESULTS

The intent-to-treat population comprised 137 patients [desloratadine (n = 65) or placebo (n = 72)]. Desloratadine treatment was associated with significantly greater improvements from baseline to day 42 compared with placebo in DLQI overall score (-6 vs. -2.2 points; P < 0.002) and VQ-Dermato score (18.5 vs. 29.1 points; P = 0.009). Mean scores for sleep disruption and disruption of daily activities were significantly lower in the desloratadine group than in the placebo group from day 1 to the end of the study.

CONCLUSIONS

Desloratadine 5 mg/day was associated with significant improvements in two separate dermatology-specific measures of QoL in patients with CIU. QoL proved to be a relevant primary outcome measure for therapeutic trials in CIU.

Cellulite and skin ageing: is there any interaction?

OBJECTIVE

This study aimed to identify the characteristics of cellulite in women of different age and to appreciate whether cellulite could interfere with skin ageing or not.

METHODS

94 Healthy females, divided into three age groups (21-30yrs; 31-40yrs; 51-60yrs) and two grade groups of cellulite (grade 2; grade 0 or control group), were investigated using non invasive techniques. The "orange peel appearance" was quantified by measuring the shadowed surfaces under low angle light. The biomechanichal properties were measured (extensibility-retractability-elasticity). The thicknesses of the skin structures were also evaluated using ultrasound. Echogenicity of the dermis was recorded and dermis density determined in two bands (superficial and low dermis).

RESULTS

In grade 2, the shadowed surfaces are significantly different according to age; i.e. smaller and more numerous after age of 30; the total skin thickness including hypodermis is increased of about 30% irrespective to age, compared to control group. The biomechanical properties of the skin are significantly modified as age increases without any grade effect. In grade 2, retractability and elasticity parameters are altered from age 30 whilst only from age 50 in the control group. Echogenicities of the superficial and deep dermis also decrease from age 30 and become significantly lower than the ones of grade 0.

CONCLUSION

Population with cellulite presents earlier skin ageing characteristics than the control population. Two sub-populations may exist: the under 30 age with large dimpled surfaces, normal biomechanical and density properties; and the over 30 age with smaller and numerous dimpled surfaces and already altered dermis properties. This premature skin ageing should be prevented accordingly.

Vitiligo pathogenesis: autoimmune disease, genetic defect, excessive reactive oxygen species, calcium imbalance, or what else?

The pathobiology of vitiligo has been hotly disputed for as long as one remembers, and has been a magnet for endless speculation. Evidently, the different schools of thought--ranging, e.g. from the concept that vitiligo essentially is a free-radical disorder to that of vitiligo being a primary autoimmune disease--imply very different consequences for the best therapeutic strategies that one should adopt. As a more effective therapy for this common, often disfiguring pigmentary disorder is direly needed, we must strive harder to settle the pathogenesis debate definitively--on the basis of sound experimental evidence, rather than by a war of dogmatic theories. Recognizing, however, that it is theories which tend to guide our experimental designs and choice of study parameters, the various pathogenesis theories on the market deserve to be critically, yet unemotionally re-evaluated. This Controversies feature invites you to do so, and to ask yourself: is there something important or worthwhile exploring in other pathogenesis scenarios than those already favoured by you that may help you improve your own study design, next time you have a fresh look at vitiligo? Vitiligo provides a superb model for the study of many fundamental problems in skin biology and pathology. Therefore, even if it later turns out that, as far as your own vitiligo pathogenesis concept is concerned, you have barked-up the wrong tree most of the time, chances are that you shall anyway have generated priceless new insights into skin function along the way.

Evaluation of efficacy and safety of rucinol serum in patients with melasma: a randomized controlled trial

BACKGROUND

Melasma is a hyperpigmentation disorder predominantly affecting sun-exposed areas in women, which is often refractory to treatment. Most commercially available treatments incorporate inhibitors of tyrosinase, a key enzyme in melanin production within the melanocyte. In general, however, the efficacy of these therapies is somewhat limited. Recent studies have identified other enzymes that play an important role in melanogenesis, including tyrosinase-related protein-1 (TRP-1), which catalyses the oxidation of the melanogenetic intermediate 5,6-dihydroxyindole-2-carbolylic acid. Rucinol (4-n-butylresorcinol) has been shown to inhibit the activity of both tyrosinase and TRP-1.

OBJECTIVES

To assess the efficacy of rucinol serum 0.3% vs. the corresponding vehicle as a treatment for melasma. Secondary objectives were to evaluate local and general tolerability and to assess the skin acceptability of rucinol serum in the target population.

METHODS

In this prospective, single-centre, double-blind, randomized, vehicle-controlled, bilateral (split-face) comparative trial, 32 women with melasma were provided with two identical tubes containing rucinol serum 0.3% or vehicle. The products were each applied to one-half of the face, according to the randomization scheme, twice daily for 12 weeks (phase 1). A broad-spectrum sunscreen (sun protection factor 60) was also applied daily. Assessments at baseline, 4, 8 and 12 weeks included clinical evaluations by a dermatologist, chromametry, ultraviolet and standard photography, and assessments of skin acceptability and tolerability. After 12 weeks, patients were given the option of an additional 3-month treatment period of open full-face rucinol treatment, with reviews at 16, 20 and 24 weeks (phase 2).

RESULTS

Twenty-eight patients completed phase 1 and 26 patients completed phase 2. After 12 weeks, the clinical pigmentation score for rucinol-treated skin was significantly lower than for vehicle-treated skin (P = 0.027). During phase 2, rucinol induced a significant reduction in mean pigmentation score on the half of the face previously treated with vehicle. There was also a further, significant improvement on the rucinol-treated side of the face. Chromametry measurements showed that skin was significantly lighter and less yellow, with a strong trend towards reduced redness, following rucinol therapy compared with vehicle. Rucinol serum showed good tolerability and acceptability and was considered to have good or fair efficacy by 78% of the patient population.

CONCLUSIONS

Rucinol serum was shown to have significant efficacy compared with vehicle alone in improving melasma after 3 months of treatment, according to clinical and objective assessments of skin colour.

Reduced Salivary Flow Induced by Systemic Isotretinoin May Lead to Dental Decay. A Prospective Clinical Study

BACKGROUND

The adverse effects of isotretinoin have been well documented, but dental side effects over the course of treatment have never been studied.

OBJECTIVES

To prospectively document the oral side effects experienced by a group of patients taking isotretinoin and to compare the changes in oral health and salivary parameters with a control group.

METHODS

A cohort study was conducted within the dermatology department at the University Hospital in collaboration with two private dermatology practices in Nice, France. Patients were treated at a dose of 0.5 mg/kg/day. The control group was made up of students from the University of Nice-Sophia-Antipolis. The salivary flow, the buffer capacity of saliva, the number of pathogen bacteria and the DMFT index (number of decayed, missing and filled teeth) were assessed at each visit.

RESULTS

Eighteen patients and 99 controls were available for evaluation. None of the oral parameters varied with time in the control group, whereas the DMFT significantly increased in the treated group (3.07 +/- 3.85 vs. 3.41 +/- 4.36; p<0.036). The salivary flow gradually decreased with time (p<0.004), but the patients recovered their baseline salivary flow 2 months after the end of the treatment.

CONCLUSIONS

This study clearly showed that patients treated with isotretinoin experienced oral side effects.

The safety of hydroquinone

Hydroquinone is one of the most effective molecules for the treatment of hyperpigmentary disorders, with over 40 years of efficacy and safety data. Concerns over its safety have been raised because of the fact that it is a derivative of benzene and because of the long-term side-effects observed with cosmetic products containing high concentrations of hydroquinone. However, despite 40-50 years use of hydroquinone for medical conditions, there has not been a single documented case of either a cutaneous or internal malignancy associated with this drug. This article reviews the evidence for the safety of hydroquinone in the treatment of hyperpigmentation conditions.

Efficacy and safety of a new single-dose terbinafine 1% formulation in patients with tinea pedis (athlete's foot): a randomized, double-blind, placebo-controlled study

BACKGROUND

Tinea pedis is a common dermatophyte infection with frequent recurrences. Terbinafine (presently used as a 1-week topical treatment of tinea pedis) is now available in a novel topical solution (film-forming solution--FFS), developed to allow single application.

OBJECTIVES

To demonstrate the efficacy and safety of terbinafine 1% FFS in a randomized, double-blind, placebo-controlled, phase III trial, and to determine relapse or re-infection rate of tinea pedis at 12 weeks.

PATIENTS/METHODS

Fifty-four centres (27 in France; 27 in Germany) enrolled 273 evaluable patients (2 : 1 randomization). Patients applied terbinafine 1% FFS or placebo only once between, under and over the toes, soles and sides of both feet. Efficacy assessments included direct microscopy, mycological culture, and clinical signs and symptoms at baseline, and at weeks 1, 6 and 12 after the single drug application.

RESULTS

Effective treatment (negative mycology plus absent/minimal symptoms) at week 6 in the terbinafine 1% FFS group was 63%; vehicle was 17% (P<or=0.0001). Mycological cure was 72% in the terbinafine group and 21% in the placebo (P<or=0.0001) at week 6. Clinical signs/symptoms decreased significantly in the active group compared to the placebo. The self-assessment of itching and burning sensation by the patient showed a clear reduction in symptoms starting 15 min after treatment application (this could be attributed to the cooling effect of the FFS). Recurrence (positive culture at 3 months) occurred in 12.5% of the effectively treated patients at week 6 in the terbinafine group. FFS was well tolerated.

CONCLUSION

Terbinafine 1% FFS, single dose application is an effective, safe and convenient treatment for tinea pedis. The relapse/re-infection rate 3 months after the end of single-dose therapy is similar to that previously demonstrated in a study using terbinafine 1% cream for 7 days.

The right dose in the right place: an overview of current prescription, instruction and application modalities for topical psoriasis treatments

BACKGROUND

Compared to treatment success with oral medications, treatment success with topical treatments is currently difficult to achieve.

AIM

To assess and compare existing methods of lesion size evaluation, prescription habits, instruction and application modalities of topical medications.

METHODS

Review of current and new procedures to estimate the body surface area, to calculate the most adequate quantity of medication to be prescribed, to instruct patients and to assess the individual dosing procedures of topical treatments.

RESULTS

The most accurate method to assess the body surface area remains the rule of nine, allowing, together with a recently developed calculation disc, to estimate the most adequate quantity of topical treatment (here calcitriol 3 g/g ointment) to be prescribed. Precise instructions to the patient are other important elements for the successful treatment of dermatoses. Dosing devices, such as a spatula, may help patients to dose their daily topical treatment, avoiding over- and underdosing of the medication.

CONCLUSION

A correct evaluation of the lesions sizes, a precise calculation of the treatments quantity to be prescribed, clear instructions and treatment-specific individual dosing devices may help to achieve higher patient compliance and treatment success.

PI3K mediates protection against TRAIL-induced apoptosis in primary human melanocytes

Melanocytes are cells of the epidermis that synthesize melanin, which is responsible for skin pigmentation. Transformation of melanocytes leads to melanoma, a highly aggressive neoplasm, which displays resistance to apoptosis. In this report, we demonstrate that TNF-related apoptosis-inducing ligand (TRAIL), which was thought to kill only transformed cells, promotes very efficiently apoptosis of primary human melanocytes, leading to activation of caspases 8, 9 and 3, and the cleavage of vital proteins. Further, we show that stem cell factor (SCF), a physiologic melanocyte growth factor that activates both the phosphatidyl-inositol-3 kinase (PI3K) and the extracellular regulated kinase (ERK) pathways, strongly protects melanocytes from TRAIL and staurosporine killing. Interestingly, inhibition of PI3K or its downstream target AKT completely blocks the antiapoptotic effect of SCF, while inhibition of ERK has only a moderate effect. Our data indicate that protection evoked by SCF/PI3K/AKT cascade is not mediated by an increase in the intracellular level of FLIP. Further, only a sustained PI3K activity can protect melanocytes from apoptosis, thereby indicating that the PI3K/AKT pathway plays a pivotal role in melanocyte survival. The results gathered in this report bring new information on the molecular mechanisms involved in primary melanocyte apoptosis and survival that would help to better understand the process by which melanomas acquire their resistance to apoptosis.

An open-label study of alefacept plus ultraviolet B light as combination therapy for chronic plaque psoriasis

BACKGROUND

Alefacept, a fully human LFA-3/IgG(1) fusion protein, is a selective biological agent approved in the United States for the treatment of chronic plaque psoriasis. In phase 3 trials, clinical improvement and prolonged off-treatment remission of psoriasis correlated with reductions in circulating memory T cells. Reductions in pathogenic epidermal T cells in psoriatic lesions also have been noted following phototherapy with ultraviolet B (UVB) light. Because alefacept and UVB target T cells in different ways, combination therapy with these two agents may lead to greater efficacy.

OBJECTIVES

To determine the safety, tolerability, and efficacy trends of combination therapy with alefacept plus UVB light in patients with chronic plaque psoriasis.

METHODS

In an open-label, parallel-group study conducted at two sites, one in France and one in the United States, patients with chronic plaque psoriasis who were candidates for phototherapy received 12-weekly intramuscular injections of alefacept, 15 mg. In addition, patients were randomized to one of three treatment arms: no UVB treatment, 6-week UVB treatment, and 12-week UVB treatment. UVB treatment consisted of narrowband (NB) UVB at the site in France and broadband (BB) UVB at the site in the United States. The 12-week treatment period was followed by a 12-week follow-up period. Clinic visits occurred weekly during treatment and every 2-4 weeks during follow-up.

RESULTS

A total of 60 patients (n = 30/site) were enrolled in the study. Alefacept was well tolerated when administered in combination with UVB treatment and as monotherapy. There was no evidence of increased phototoxicity or photosensitivity with the combination. At each study site, alefacept/UVB provided a higher overall response rate and led to a more rapid onset of response compared with alefacept monotherapy. Of patients who achieved > or = 50% reduction from baseline Psoriasis Area Severity Index (PASI 50) at 2 weeks after the last dose of alefacept, 75-100% in the combination therapy groups maintained this response throughout follow-up in the absence of further psoriasis therapy.

CONCLUSIONS

In patients with chronic plaque psoriasis, combination therapy with alefacept plus short-term (6-12 weeks) UVB treatment is well tolerated with a trend toward greater and more rapid efficacy than alefacept alone.

Treatment of vitiligo by 308-nm excimer laser: an evaluation of variables affecting treatment response

BACKGROUND AND OBJECTIVES

To determine the true efficacy of the 308-nm excimer laser for the treatment of vitiligo, while taking into account confounding factors such as anatomic site of treatment, age, sex, skin type, MED, and duration of evolution of the vitiligo.

STUDY DESIGN/MATERIALS AND METHODS

Thirty-five patients with vitiligo were included. Each lesion was treated twice a week by the 308-nm excimer laser for a maximum of 24 sessions. Efficacy was blindly evaluated by two independent physicians.

RESULTS

Repigmentation was noted in 46 plaques/52 (88.5%). Repigmentation rate (75%) was obtained in 14 (26.9%). In "UV sensitive" areas (face, neck, trunk), 8/14 lesions (57.1%) had a repigmentation rate, 75% versus 6/38 (15.8%) in "UV resistant" areas (bony prominences and extremities) (P = 0.031). No relationship could be established between response to the treatment and the following variables: age, sex, skin type, MED, and duration of evolution of the vitiligo (respectively, P = 1, 0.666, 0.566, 0.628, 0.521).

CONCLUSIONS

An aesthetically reasonable result is achieved essentially in "UV sensitive" areas, thus appearing to be the appropriate places of choice for this treatment.

A multicentre, randomized, double-blind, controlled study of long-term treatment with 0.1% tacrolimus ointment in adults with moderate to severe atopic dermatitis

BACKGROUND

Atopic dermatis (AD) is a chronic disease that often requires long-term treatment. Topical corticosteroids are the usual therapy for patients with AD, but prolonged usage can result in skin atrophy and other side-effects.

OBJECTIVES

In a randomized, double-blind, comparative study, to compare the efficacy and safety of a 6-month treatment period with 0.1% tacrolimus ointment vs. a corticosteroid ointment regimen in adults with moderate to severe AD.

METHODS

Treatment was applied twice daily for a maximum of 6 months. Patients in the tacrolimus treatment group (n = 487) applied 0.1% tacrolimus ointment to all affected areas over the whole body. The patients treated with the corticosteroid regimen (n = 485) applied 0.1% hydrocortisone butyrate ointment to affected areas on the trunk and extremities and 1% hydrocortisone acetate ointment to affected areas on the face and neck. The study primary endpoint was the response rate, i.e. the proportion of patients with at least 60% improvement in the modified Eczema Area and Severity Index (mEASI) between baseline and month 3.

RESULTS

By month 3, more patients in the 0.1% tacrolimus group responded to treatment (72.6% vs. 52.3% in the corticosteroid group, P < 0.001). The patients treated with 0.1% tacrolimus also showed greater improvement in mEASI, EASI, affected body surface area and physician and patient assessments of global response. Patients applying 0.1% tacrolimus ointment experienced more skin burning (52.4% vs. 13.8% in the corticosteroid group; P < 0.001). In most patients, skin burning was mild to moderate in severity and decreased rapidly after the first week of treatment. There was no increase in the incidence of infections or malignancies over time in either treatment group.

CONCLUSIONS

Long-term treatment with 0.1% tacrolimus ointment is significantly more efficacious than a corticosteroid ointment regimen in adults with moderate to severe AD.

Diclofenac-Na Gel Is Effective in Reducing the Pain and Inflammation Associated with Exposure to Ultraviolet Light – Results of Two Clinical Studies

The potential of a diclofenac-Na Emulgel (diclofenac gel) to alleviate the pain and associated symptoms caused by sunburn has been evaluated versus vehicle. Sunburn was induced on the buttock skin of healthy adult male subjects by irradiation with UVA + UVB rays. Investigational products were applied 6 and 10 h after irradiation, and efficacy was assessed on the basis of spontaneous and provoked pain, erythema, oedema, skin colour and temperature. The minimal efficacious concentration evaluated in an extension (0.1 vs. 0.25% diclofenac gel) of a previous concentration-finding study (1, 0.5 and 0.25% diclofenac gel) was 0.1% and was efficacious in alleviating pain (spontaneous and provoked) as well as reducing erythema, oedema and skin temperature. In a single- versus 2-application comparison study, a single application of 0.1% gel was sufficient to alleviate the pain and accompanying symptoms of sunburn with an onset of action 2 h after application. A second application of gel 4 h after the first maintained the analgesia and reduction of other symptoms for a period of up to 48 h after irradiation.

Comparative study of the impact of chronic urticaria, psoriasis and atopic dermatitis on the quality of life

BACKGROUND

A better management of chronic skin disorders (CSDs) requires a knowledge of their impact from the patient's point of view.

OBJECTIVES

To determine which aspects of the patient's life are mainly impaired in the different CSDs, and provide comparative references to estimate better the real impact of the different CSDs.

PATIENTS AND METHODS

A prospective cross-sectional and matched study of 1356 adult outpatients to compare the health-related quality of life (HRQL) profile in chronic urticaria (466 CU), psoriasis (464 PSO) and atopic dermatitis (426 AD), using the VQ-Dermato, a multidimensional instrument in French validated for CSDs.

RESULTS

After adjustment for confounders, HRQL dimensions were differently affected in the three CSDs. The 'physical discomfort' dimension was more degraded in AD and CU than in PSO (P < 0.001), and 'leisure activities' more in PSO than in CU (P < 0.001). 'Self-perception' and 'treatment-induced restrictions' dimensions were much less affected in CU than in PSO and AD (P < 0.001). In PSO, the 'daily living activities' dimension was much less impaired than in CU and AD (P < 0.001). No aspect of HRQL was really spared in AD.

CONCLUSIONS

The comparison shows that CU, PSO and AD are characterized by completely different qualitative profiles of impact on HRQL, which are influenced by their clinical characteristics and usual treatment options. It underlines the severe impairment of CU which is often underestimated.

Efficacy of once-daily treatment regimens with calcipotriol/betamethasone dipropionate ointment and calcipotriol ointment in psoriasis vulgaris

BACKGROUND

A two-compound ointment containing calcipotriol 50 micro g g-1 and betamethasone dipropionate 0.5 mg g-1 has recently been shown to be an effective treatment for psoriasis.

OBJECTIVES

This study was designed to investigate efficacy and safety of different treatment regimens with the two-compound product (Daivobet/Dovobet; LEO Pharma, Ballerup, Denmark) and calcipotriol 50 micro g g-1 ointment (Daivonex/Dovonex; LEO Pharma).

METHODS

In total, 972 patients with psoriasis vulgaris were randomized to one of three treatment regimens: group 1, the two-compound product once daily for 8 weeks followed by calcipotriol ointment once daily for 4 weeks; group 2, the two-compound product once daily for 4 weeks followed by 8 weeks of treatment with calcipotriol ointment once daily on weekdays and the two-compound product once daily at weekends; and group 3, calcipotriol ointment twice daily for 12 weeks. The efficacy was evaluated by Psoriasis Area and Severity Index (PASI) and investigators' global assessments of disease severity. The primary response criteria were percentage reduction in PASI and proportion of patients with absent/very mild disease according to the investigators' global assessments after 8 weeks of treatment.

RESULTS

The mean reduction in PASI from baseline to the end of 8 weeks of treatment was 73.3% for group 1, 68.2% for group 2 and 64.1% for group 3. The proportion of patients with absent/very mild disease at the end of 8 weeks of treatment was 55.3% for group 1, 47.7% for group 2 and 40.7% for group 3. For both primary response criteria, group 1 was statistically superior to group 3 (P < 0.001), whereas group 2 did not differ significantly from group 3. The difference between group 1 and group 2 was statistically significant with regard to PASI but not regarding the proportion of patients with absent/very mild disease. Patients receiving initial therapy with the two-compound product achieved the fastest treatment response, and the maximum treatment effect for these patients was seen after 5 weeks. This effect was maintained with continued treatment with the two-compound product for up to 8 weeks. After 12 weeks of treatment, no significant differences were seen between the three groups with regard to reduction in PASI, whereas the proportion of patients with absent/very mild disease in group 2 was superior to that in group 3. Patients receiving therapy with the two-compound product experienced fewer lesional/perilesional adverse drug reactions than the calcipotriol-treated patients (P < 0.001): 10.9% in group 1, 11.5% in group 2 and 22.3% in group 3.

CONCLUSIONS

Two different short-term treatment regimens employing a recently developed two-compound product (calcipotriol/betamethasone dipropionate) provided rapid and marked clinical efficacy and were shown to be safe therapies for psoriasis vulgaris.

Diagnostic and neural analysis of skin cancer (DANAOS). A multicentre study for collection and computer-aided analysis of data from pigmented skin lesions using digital dermoscopy

BACKGROUND

Early detection of melanomas by means of diverse screening campaigns is an important step towards a reduction in mortality. Computer-aided analysis of digital images obtained by dermoscopy has been reported to be an accurate, practical and time-saving tool for the evaluation of pigmented skin lesions (PSLs). A prototype for the computer-aided diagnosis of PSLs using artificial neural networks (NNs) has recently been developed: diagnostic and neural analysis of skin cancer (DANAOS).

OBJECTIVES

To demonstrate the accuracy of PSL diagnosis by the DANAOS expert system, a multicentre study on a diverse multinational population was conducted.

METHODS

A calibrated camera system was developed and used to collect images of PSLs in a multicentre study in 13 dermatology centres in nine European countries. The dataset was used to train an NN expert system for the computer-aided diagnosis of melanoma. We analysed different aspects of the data collection and its influence on the performance of the expert system. The NN expert system was trained with a dataset of 2218 dermoscopic images of PSLs.

RESULTS

The resulting expert system showed a performance similar to that of dermatologists as published in the literature. The performance depended on the size and quality of the database and its selection.

CONCLUSIONS

The need for a large database, the usefulness of multicentre data collection, as well as the benefit of a representative collection of cases from clinical practice, were demonstrated in this trial. Images that were difficult to classify using the NN expert system were not identical to those found difficult to classify by clinicians. We suggest therefore that the combination of clinician and computer may potentially increase the accuracy of PSL diagnosis. This may result in improved detection of melanoma and a reduction in unnecessary excisions.

Intra-individual comparison of the cutaneous safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or flexural areas

BACKGROUND

Psoriasis involving sensitive skin areas remains difficult to treat because of the side-effects of topical corticosteroids and the irritancy potential of vitamin D3 derivatives. Several clinical trials have demonstrated that calcitriol, the naturally occurring and hormonally active form of vitamin D3, is effective and safe at the dose of 3 microg g(-1) for the treatment of psoriasis affecting the trunk and limbs.

METHODS

We compared the safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment in a multicentre, randomized, investigator-blinded, left-right comparison in mild to moderate chronic plaque psoriasis affecting sensitive areas, defined as being the face, hairline, retroauricular and flexural areas. One pair of symmetrical and bilateral target lesions was selected from each area and assessed for perilesional erythema, oedema, and stinging/burning. Global assessment of local tolerability and global improvement were rated by the investigator, and the subjects were asked to evaluate the tolerability and efficacy of each product and to express their global preference.

RESULTS

In the 75 subjects, calcitriol and calcipotriol both led to clearing of at least one target lesion in 21 (28%) of the subjects each. Perilesional erythema (P < 0.001), perilesional oedema (P < 0.02) and stinging/burning (P < 0.001) were all significantly less severe with calcitriol than with calcipotriol. The subjects' evaluation of local tolerability was significantly (P < 0.0001) in favour of calcitriol. Ten treatment-related dermatological events occurred in eight subjects, including one subject who experienced skin discomfort on both sides. All other events occurred only on the calcipotriol-treated side (irritant dermatitis, six subjects; contact dermatitis, one subject). Global assessment of improvement from baseline by the investigators was significantly greater for the calcitriol-treated lesions (P < 0.02). The subjects' global preference was significantly in favour of calcitriol (P < 0.02).

CONCLUSIONS

In the present study, calcitriol ointment was found to be better tolerated and would appear to be more effective than calcipotriol ointment in the treatment of psoriasis in sensitive areas.

A new calcipotriol/betamethasone formulation with rapid onset of action was superior to monotherapy with betamethasone dipropionate or calcipotriol in psoriasis vulgaris

In this study, we compared a new combination ointment containing both calcipotriol and betamethasone dipropionate with betamethasone dipropionate ointment (Diprosone) and calcipotriol ointment (Daivonex) in patients with psoriasis vulgaris; 1106 patients were randomized to twice daily double-blind treatment with combination, betamethasone dipropionate or calcipotriol for 4 weeks. Patients then received twice daily calcipotriol, unblinded, for a further 4 weeks. Mean percentage change in PASI at end of the double-blind phase was -74.4 (combination group), -61.3 (betamethasone group) and -55.3 (calcipotriol group). Mean difference (95% Cl) combination-betamethasone was -13.1 (-16.9 to -9.3, p < 0.001) and for combination-calcipotriol -19.0 (-22.8 to -15.2, p <0.001). The differences in PASI were also statistically significant after 1 week. In the double-blind phase, 8.1% of patients (combination) reported lesional/ perilesional adverse reactions compared to 4.7% (betamethasone) and 12.0% (calcipotriol). In the combination group, mean PASI at the end of the double-blind phase was 2.5, and at end of the unblinded phase 3.6, compared with 3.9 and 4.1 (betamethasone) and 4.4 and 3.7 (calcipotriol). Calcipotriol/betamethasone combination is more effective and has a more rapid onset of action than either active constituent used alone, and is well tolerated. It is safe to transfer patients from combination to calcipotriol, with maintenance of clinical effect.

[Noninvoluting congenital hemangioma: 2 cases]

INTRODUCTION

Hemangiomas (or immature hemangiomas) are characterized by a stereotyped 3-phase evolution: proliferation, stabilization and regression. The rare congenital hemangiomas are present at birth and regress spontaneously more rapidly. However, certain congenital hemangiomas, described recently as "noninvoluting congenital hemangiomas", evolve differently and do not regress. We report two cases.

OBSERVATIONS

Two adolescents aged 16 and 17 were born with a congenital hemangioma. Its evolution during childhood was marked by the progressive collapse of the lesion and lightening of the skin. After stabilizing, a round, centrally involuted lesion persisted with numerous telangiectasia on the surface and peripheral varicosities. The lesion was hot but no pulsation or murmur were observed. Doppler sonography revealed a rapid flowing lesion, limited to the cutaneous areas. Magnetic resonance imaging, conducted in one case, showed a hypersignal area limited to the skin.

DISCUSSION

Noninvoluting congenital hemangiomas can be differentiated from classical congenital hemangiomas by their partial regression, stereotyped clinical aspect and a certain activity after stabilization. All the clinical, histological and imaging data support a vascular malformation with proliferative component, rather than a true hemangioma. Whenever possible, treatment is surgical. Knowledge of the existence of this type of angioma is important, and the dermatologist should be careful when reassuring parents of children presenting with congenital hemangioma.

Treatment of vitiligo by topical calcipotriol

OBJECTIVE

Evaluation of the efficiency of topical calcipotriol monotherapy in vitiligo.

MATERIALS AND METHODS

This was a prospective, right/left comparative, open study at the Dermatology Department at the University Hospital in Nice, France. Twenty-four patients with localized or generalized vitiligo with symmetrical lesions were included. The main outcome measure was the evaluation of the percentage of repigmentation in treated target lesions and untreated control lesions for each patient.

RESULTS AND CONCLUSIONS

Topical calcipotriol in monotherapy is not an effective treatment of vitiligo.

[Cutaneous Waldenström's macroglobulinemia]

BACKGROUND

We report the case of a patient in whom the first manifestation of Waldenström' s macroglobulinemia was specific skin lesions, treated with chlorambucil chemotherapy.

CASE REPORT

A 76-years old woman was referred to us because of chronic red nodular lesions on her face. A biopsy specimen showed a dense lymphocytic dermal infiltrate and immunohistochemistry identified a monoclonal B lymphoid population with an IgM-kappa phenotype. The patient's disease was diagnosed as Waldenström's macroglobulinemia with cutaneous localization, on the basis of a high level of circulating macroglobulinemia and a lymphoplasmocytic infiltrate in the bone marrow expressing the same monoclonal IgM-kappa as in blood and skin. Treatment with radiotherapy (12 Grays) was unsuccessful. Chlorambucil (16 mg per day, 7 days per month) was then introduced with rapid disappearance of the skin lesions. Neutropenia led to withdrawal of this treatment after 4 courses. The skin lesions relapsed 18 months later and were cured with chlorambucil at a lower dose.

DISCUSSION

Specific skin infiltrates have been rarely described during Waldenström's macroglobulinemia. Review of the literature showed eight cases of such lesions treated by chemotherapy with only two successes with oral cyclophosphamide and polychemotherapy (cyclophosphamide, vincristine and CCNU). Chlorambucil was used unsuccessfully three times. We hypothesize that primary resistance to alkylating-agent and the small number of cases of cutaneous Waldenström's macroglobulinemia may explain the poor response to systemic chemotherapy previously reported.