Topical preparations for the treatment of psoriasis: a systematic review

Abstract

Summary Background There is clinical uncertainty about the appropriate use of first‐line topical treatments for psoriasis. Objectives To assess the relative effectiveness and tolerability of topical treatments for psoriasis suitable for use both in primary and secondary care. Methods All major medical databases of published literature were searched electronically; references of trial reports and recent reviews were searched; authors and companies were contacted for missing data from published reports. The study selection comprised: (1) randomized placebo‐controlled trials of topical treatments for psoriasis; and (2) randomized head‐to‐head studies of the new vitamin D3 derivative treatments for psoriasis that reported clinical outcome using a Total Severity Score (TSS), Psoriasis Area Severity Index or Investigator Assessment of Global Improvement. Eligibility and validity were assessed and data extracted independently by two authors. Clinical outcomes were pooled using a random effect standardized weighted mean difference (SWMD) metric, including 3380 patients randomized in 41 placebo (vehicle)‐controlled trials and 4898 patients randomized in 28 head‐to‐head studies. Results There was a significant benefit in favour of active treatments against vehicle, SWMD: −1·06 (95% confidence interval [CI]: −1·26 to −0·86), approximately a 2‐point improvement on a 12‐point TSS after 6–8 weeks of treatment. The only significantly different benefit was for very potent corticosteroids: SWMD: −1·51 (95% CI: −1·76 to −1·25), approximately a 3‐point improvement on a 12‐point TSS. Head‐to‐head studies support these findings, except that calcipotriol was estimated to be more effective than dithranol, coal tar and other vitamin D3 derivatives. Polytherapy, using a potent steroid and calcipotriol, was more effective than calcipotriol alone: SWMD 0·42 (95% CI: 0·12–0·72) approximately a 0·8‐point improvement on a 12‐point TSS. No important differences in withdrawal or reporting of adverse events were identified. Conclusions Trials of short duration neither adequately inform the management of chronic disease nor describe the sequelae of treatment. The evidence base for long‐term care, reflecting the disease pathway, should be improved. Combination therapy with topical vitamin D analogues and steroids, and maintenance therapy following treatment response merit further investigation.

The two-compound formulation of calcipotriol and betamethasone dipropionate for treatment of moderately severe body and scalp psoriasis – an introduction

“…This analysis indicated that relative to all the commonly used topicals studied [except for the unlicensed twice daily application of the TCF], the TCF once daily was considered to be the most efficacious treatment for plaque psoriasis since robust evidence and state of the art evidence assimilation techniques showed a higher efficacy based on PASI 75 and CFB in PASI score. The MTC observations are consistent with results of two metaanalyses that did not include the TCF, which demonstrated that the non-fixed combination of a potent topical corticosteroid plus calcipotriol was more efficacious than calcipotriol 45,46 , and in accord with an indirect unadjusted comparison which indicated that the TCF provided higher PASI 75 response rates than the non-fixed combination and other commonly used topicals 29 . There are few national clinical guidelines for the management of scalp psoriasis; the issues relating to treatment of scalp lesions are often neglected in psoriasis treatment guidelines 47 although its challenges are mentioned in the recent British Association of Dermatologists and Primary Care Dermatology Society recommendations for the initial management of psoriasis 48 .…”

Scalp psoriasis: European consensus on grading and treatment algorithm

“…One meta-analysis identified only 42 well-designed, placebo-controlled trials of topical agents for the treatment of psoriasis, with only 7 focusing specifically on scalp psoriasis. 12 Most trials only cover short-term treatment. This section briefly reviews the efficacy, safety, and convenience of the most significant available topical treatments, and comments on the quality of evidence.…”

Chronic Plaque Psoriasis

“…Topical steroids have been the mainstays of treatment for many years. Multiple randomised controlled trials 17 (RCTs) have found that potent (e.g., mometasone [Elocon®] ointment) and very potent (e.g., clobetasol [Dermovate®]) topical steroids improve psoriasis plaques. The major limitation of these studies is their short duration, averaging only four weeks.…”

“…[17][18][19][20][21][22][23][24][25][26][27] Topical Steroids. Topical steroids have been the mainstays of treatment for many years.…”