Topical calcipotriol therapy in nail psoriasis: a study of 24 cases

There are few reports regarding the treatment of nail psoriasis with topical calcipotriol. We undertook a case series study to evaluate the efficacy and safety of calcipotriol ointment (50 microg/g) in the treatment of nail psoriasis in 24 patients. This study involved 19 women and 5 men with nail psoriasis referred to Dermatology clinics of Razi hospital. The duration of trial was from October 2002 to September 2004. Informed consent was obtained from all patients before entering into the study. The patients applied calcipotriol ointment to the affected nails twice daily without occlusion for 3 months. Patients were seen by two academic dermatologists initially, after 2 weeks, and then at monthly intervals. The efficacy and safety were clinically assessed and any side effect was recorded. Patients who showed 50 percent or greater reduction in the baseline subungual thickness in at least one nail were considered to be responders and were offered continuation of therapy for an additional 2 months. After discontinuation of therapy, followup visits were performed at 1 and 2 months. After 3 months of therapy, fourteen patients showed significant clinical improvement, two of them were completely free from nail lesions after 5 months. Calcipotriol was particularly effective in subungual hyperkeratosis, onycholysis, and discoloration. In four patients fingertip tenderness and in one case the pain of involved distal phalanx were significantly reduced. No clinical response was observed in four patients. Only two cases showed adverse reactions. Topical Calcipotriol is an effective treatment for nail psoriasis and can be considered to be a safe topical treatment in chronic cases; its high tolerability allows prolonged usage without severe side effects.     

Treatment of severe nail psoriasis with acitretin: an impressive therapeutic result

Nail psoriasis is common in adult psoriatic patients. Although several new drugs have recently been introduced for the treatment of skin psoriasis, treatment of nail psoriasis still remains a challenge. Topical treatments (e.g., corticosteroids, tazarotene, 5‐fluorouracil, calcipotriol) are the first line in the management of skin psoriasis. The efficacy of these drugs in nail disease, however, is limited, mainly due to the difficulty in penetrating the nail bed and nail matrix. In cases of nail disease resistant to topical treatment, methotrexate, ciclosporin, acitretin, or biological agents can be used. The present authors introduce a 73‐year‐old patient affected by impressive psoriatic nail disease involving all her fingernails and toenails treated by acitretin, a traditional systemic treatment. After 2 months of treatment there was a marked improvement. The clinical improvement of the nails was progressive and 6 months later it was stable and satisfactory. The remarkable response to treatment in this case suggests that oral acitretin, in association to urea nail lacquer, might be useful in the management of disabling severe nail psoriasis even in absence of severe cutaneous involvement.     

An Open Label Prospective Randomized Trial to Compare the Efficacy of Coal Tar-Salicylic Acid Ointment Versus Calcipotriol/Betamethasone Dipropionate Ointment in the Treatment of Limited Chronic Plaque Psoriasis

Background:Chronic plaque psoriasis is a common papulosquamous skin disorder, for which a number of topical agents are being used including coal tar, topical steroids and more recently topical calcipotriol/betamethasone dipropionate. There is no study comparing purified coal tar preparation with calcipotriol/betamethasone dipropionate ointment in limited chronic plaque psoriasis.Results:Mean PASI was significantly lower at week 2 (P = 0.01) and week 4 follow-up (P = 0.05) and the mean reduction in PASI was significantly higher at week 2 (P = 0.02) with calcipotriol/betamethasone than coal tar-salicylic acid, but this difference was not sustained at subsequent follow-up visits. Similarly, PGA scores at weeks 2 and 4 were significantly lower with calcipotriol/betamethasone dipropionate ointment (P = 0.003 and P = 0.007 respectively). There was no significant difference in any parameter during subsequent follow-up visits or at the end of the treatment phase (12 weeks).Conclusion:Topical nightly application of calcipotriol/betamethasone dipropionate ointment leads to an initial, more rapid reduction in disease severity, but the overall outcome parameters are comparable in the two treatment groups.     

Comparison of calcipotriol monotherapy and a combination of calcipotriol and betamethasone valerate after 2 weeks' treatment with calcipotriol in the topical therapy of psoriasis vulgaris: a multicentre, double-blind, randomized study

A clinical study was conducted to determine whether, in the topical treatment of psoriasis, a combination of calcipotriol and betamethasone valerate after previous treatment with calcipotriol alone was more effective than the continuation of the monotherapy with calcipotriol, especially in 'low responders'. Patients ( n  = 169) with the clinical diagnosis 'chronic plaque-type psoriasis' were treated twice daily for 2 weeks with calcipotriol, followed by a 4-week treatment with calcipotriol monotherapy in 87 patients or combined calcipotriol/betamethasone valerate in 82 patients; all patients were followed for 8 weeks. The psoriasis area and severity index (PASI) was used to compare the two treatment groups. The overall therapeutic result was also assessed by the investigators and patients. The combination therapy was more effective, as assessed by all evaluated variables; moreover, patients showing insufficient response to calcipotriol alone after 2 weeks showed a regression of psoriatic lesions using the combination regimen. Thus, the combination of calcipotriol and topical steroids is recommended as the therapy of first choice for patients who do not respond well to treatment with 2 weeks of calcipotriol alone. Furthermore, this combination reduces the hazards associated with the long-term use of topical corticosteroids (atrophy and rebound) as well as the irritation associated with calcipotriol.     

UVA1光疗联合卡泊三醇软膏治疗甲银屑病的临床疗效观察

目的探讨UVA1光疗联合卡泊三醇软膏治疗甲银屑病的临床疗效,进而为甲银屑病患者的治疗提供临床依据。方法将收集的60例寻常型银屑病甲损害的患者随机分为2组,均给予卡泊三醇软膏2次/d,联合治疗组予以UVA1照射(2次/周)治疗,2组治疗方案疗程均为6个月;在治疗前及治疗后,对患者进行银屑病甲严重程度指数(NAPSI)。结果 60例寻常型银屑病甲损害患者中,平均年龄(50.57±16.24)岁,2组在年龄、性别、病程比较差异无统计学意义(P0.05);2组患者病甲治疗前NAPSI评分:联合治疗组:27.07±10.86,卡泊三醇软膏组:25.93±10.73,2组比较差异无统计学意义(t=0.449,P0.05);治疗后2组NAPSI评分分别为:联合治疗组:12.67±7.60,卡泊三醇软膏组:18.10±8.93,NAPSI评分差异有统计学意义(P0.05);治疗后联合治疗组临床痊愈10例,痊愈率33.33%,有效率56.67%,卡泊三醇软膏组临床痊愈0例,痊愈率0%,有效率13.33%,2组有效率的比较有统计学意义(P0.01)。结论UVA1联合卡泊三醇软膏治疗甲银屑病的疗效优于单纯使用卡泊三醇软膏。     

Treatment of inflammatory nail disorders

This article provides an updated review on diagnosis and treatment of inflammatory nail disorders including psoriasis, lichen planus, trachyonychia, and autoimmune bullous disorders. Despite the significant negative repercussion of the nail psoriasis in the quality of life of patients, treatment is often not sufficiently effective. The efficacy of topical therapies is limited to nail bed psoriasis. Intralesional corticosteroid injections are extensively utilized in nail matrix psoriasis. Systemic immunosuppressant drugs such as methotrexate and cyclosporine have shown efficacy. Biologics, particularly infliximab and etanercept, have also demonstrated high efficacy in the treatment of severe nail disease. Nail matrix lichen planus can cause nail atrophy and irreversible nail scarring and requires prompt treatment with systemic steroids. There is not gold standard therapy for trachyonychia, but in most cases the nail signs improve spontaneously and treatment is not necessary. Nail changes in pemphigus and other autoimmune disorders respond promptly to systemic therapy with steroids and immunosuppressants.     

Tratamiento de la psoriasis en placas con propiltiouracilo tópico

—Background: in recent years there are several reports that show the efficacy of both oral and topical antithyroid drugs (propylthiouracil and methimazole) in the treatment of plaque-type psoriasis.Objective: to determine the efficacy of topical propylthiouracil (5% cream) in comparison with calcipotriol ointment in the treatment of patients with plaque-type psoriasis.Materials and methods: a prospective, randomized comparison of calcipotriol ointment (14 patients) and propylthiouracil 5% cream (14 patients) was carried out.Results: there were no statistically differences between the PASI scores at 4 and 8 week from baseline in the group of patients treated with topical propylthiouracil. The differences in the PASI scores from baseline were statistically significantly in favour of calcipotriol.Conclusions: topical propylthiouracil is not an effective therapy in patients with plaque-type psoriasis.     

Tumor Necrosis Factor-α Inhibitor-Induced Psoriasis or Psoriasiform Exanthemata

Tumor necrosis factor-alpha (TNFalpha) inhibition is effective in the treatment of moderate-to-severe psoriasis. We report on 120 patients from the literature including six new patients (three women and three men) who developed pustular lesions during treatment with TNFalpha inhibitors. We identified 72 women and 36 men (several papers did not specify the gender of patients) with an age range of 13-78 years (mean 42.3 years). The primary diagnoses were rheumatoid arthritis (n = 61), ankylosing spondylitis (n = 21), psoriasis (n = 10), Crohn disease (n = 8), SAPHO (synovitis acne pustulosis hyperostosis osteitis) syndrome (n = 3), psoriatic arthritis (n = 2), and other diagnoses (n = 15). Psoriasis (except palmoplantar pustular type) was the most common adverse effect during anti-TNFalpha treatment (n = 73), followed by palmoplantar pustular psoriasis (n = 37) and psoriasis of the nail (n = 6), sometimes combined in the same patient. Palmoplantar pustulosis and psoriasiform exanthema was the diagnosis in ten patients each. A positive personal history of psoriasis was recorded in 25 patients. A positive family history was noted in eight patients. No data about personal (n = 7) or family history (n = 46) were available in a number of patients. Newly induced psoriasis was diagnosed in 74 patients whereas an exacerbation or aggravation of a pre-existing psoriasis was noted in another 25 patients. All three TNFalpha inhibitors available on the market were involved: infliximab (63 patients), etanercept (37 patients), and adalimumab (26 patients). Several patients were treated with more than a single TFNalpha inhibitor. The timing of cutaneous adverse effects (psoriasis and psoriasiform rash) varied considerably among patients, ranging from after a single application to a delayed response of up to 63 months after initiation of treatment. The mean time to appearance of the cutaneous adverse effect for all TNFalpha inhibitors was 9.5 months. Cessation of the responsible TNFalpha inhibitor was carried out in 47 patients either alone or in association with adjuvant anti-psoriatic therapy (mostly topical). This resulted in complete remission in 21 patients, partial remission in 20 patients, and stable disease in another three patients; in the other three patients, the outcome was not reported. TNFalpha inhibition was continued in 47 patients but anti-psoriatic adjuvant therapy was introduced. The outcome in this group was complete remission in 22 patients, partial remission in 25 patients, and stable disease in 2 patients. The response rate (complete remission plus partial remission) was 93.2% and 95.9%, respectively, in each group. In six patients, switching from one TNFalpha inhibitor to another one immediately after cutaneous adverse effects occurred resulted in an improvement in five patients. In nine patients, a second TNFalpha inhibitor was initiated after a break in TNFalpha inhibition. The response to a second or third drug in these patients was mixed. The underlying pathomechanisms of induction of psoriasis or psoriasiform exanthemata by TNFalpha inhibitors remain elusive but there is reason to assume that induction of such adverse events has more than one pathophysiology.     

Nail psoriasis improvement in a patient treated with fumaric acid esters

Nail psoriasis is common in adult psoriatic patients and it causes serious psychological and physical distress. Topical treatments such as corticosteroids, calcipotriol, retinoids, and 5-fluorouracil have limited efficacy and are not without side effects. Relative effective systemic treatments are ciclosporin, methotrexate and acitretin, all of which have a serious toxicity potential. Biologics in the treatment of nail psoriasis have been the subject of recent research, but their cost-effectiveness is questionable. We present a case of psoriatic nail disease which improved greatly on treatment with fumaric acid esters (FAE).     

Psoriasis in besonderen Lokalisationen

A large proportion of patients with plaque psoriasis suffer from psoriatic lesions of the scalp, nails, and intertrigines. These locations can also be soley or predominantly affected. Scalp psoriasis, nail psoriasis, and inverse psoriasis are often perceived as particularly stigmatizing. Involvement of these parts of the body is associated with an increased risk of psoriatic arthritis. Location-specific features must be considered when choosing treatment. Evidence for topical therapy of scalp psoriasis with steroids and combinations of steroids and vitamin D analogues is high. These agents are regarded as safe and effective treatments of first choice. Efficacy of TNF antagonists and apremilast is well documented for refractory scalp psoriasis. Nail psoriasis often responds insufficiently to topical therapy. Several effective systemic medications including methotrexate and TNF antagonists are available for treatment of severe forms. Controlled trials for treatment of inverse psoriasis are scarce. Topical steroids, vitamin D analogues, dithranol, and off-label calcineurin inhibitors are used in clinical practice. This review provides a survey on the clinical presentation and current evidence for treatment of psoriasis in challenging locations.     

Oral PUVA and topical steroids for treatment of oral manifestations of chronic graft-vs.-host disease

BACKGROUND: Oral manifestations of chronic graft-vs.-host disease (cGVHD) can significantly affect the quality of life and severity often does not correlate with systemic manifestations. We evaluated the use of topical corticosteroids and the intraoral application of psoralen-UVA (PUVA) for treatment of oral manifestations of cGVHD. METHODS: Overall, 18 patients with oral manifestations of cGVHD were treated with either intraoral PUVA (n=7) or with topical corticosteroids (n=16). Four patients received intraoral PUVA after failure of topical steroids and one patient was treated with topical corticosteroids after failing treatment with intraoral PUVA. A glass fiber extension of an UVA source was used for manual intraoral application. Treatment with topical corticosteroids consisted of 0.1 mg/ml dexamethasone mouth wash four times a day in combination with antifungal prophylaxis. RESULTS: Four patients showed complete local response (CR) due to intraoral PUVA, two improved and one did not respond. Topical corticosteroids resulted in nine patients in CR, two improved and five did not respond. CONCLUSION: Intraoral PUVA as well as topical corticosteroids are effective in treatment of oral manifestations of oral GVHD with few side-effects and improve quality of life in patients with cGVHD.     

Pustular psoriasis of pregnancy

The case of an 18 year old woman who developed generalized pustular psoriasis of pregnancy in the 23rd week of her first pregnancy is reported. Treatment with topical therapies was unsuccessful and oral steroids were introduced with rapid response.     

Successful Treatment of Pediatric Nail Psoriasis with Periodic Pustular Eruption Using Topical Indigo Naturalis Oil Extract

Abstract: Psoriasis of the nail greatly affects quality of life because of the difficulty in achieving long‐lasting remission. Pustular psoriasis of the nail apparatus is characterized by the formation of sterile pustules, starting on one or two fingers or less often on the toes, and spontaneous improvement has rarely been observed. This case presents a girl with refractory nail psoriasis accompanied by periodic pustular eruption that responded well to topical treatment with indigo naturalis oil extract drops, achieving a remission of longer than 1 year.     

Apoptosis, P53 and Bcl-2 expression in response to topical calcipotriol therapy for psoriasis

BACKGROUND: The histopathologic changes characteristic of psoriasis might be related to suppressed apoptosis. The P53 and Bcl-2 proteins play a central role in the regulation of apoptosis. This study aimed to evaluate P53 and Bcl-2 expression and apoptotic cells in the psoriatic skin before and after topical calcipotriol therapy. METHODS: Skin biopsies were obtained from nonlesional and lesional skin of 10 patients with generalized plaque psoriasis before and after treatment with topical calcipotriol ointment. The P53 and Bcl-2 expression was evaluated using immunoperoxidase technique and apoptotic cells by the terminal deoxynucleotide transferase (TdT) mediated deoxyuridine triphosphate nick end labeling (TUNEL) method. RESULTS: After topical calcipotriol therapy, keratinocytes of psoriatic skin showed significant decrease of P53 (P = 0.002) and increase of Bcl-2 (P = 0.01) expression. On the other hand lymphocytes showed significant decrease of Bcl-2 (P = 0.01). There were no apoptotic cells before treatment but after calcipotriol therapy, apoptosis was more detectable in keratinocytes than in lymphocytes. CONCLUSIONS: The results of the study suggested that one of the actions of calcipotriol in psoriasis might be exerted through induction of apoptosis, especially of keratinocytes, through a P53-independent pathway. Meanwhile, suppression of Bcl-2 expression in lymphocytes may promote apoptosis of dermal lymphocytes leading to healing of psoriasis.     

Psoriasis in children: a retrospective analysis

Background Few epidemiological studies are available on childhood psoriasis. Methods Between 2005 and 2008, information was collected about all children diagnosed with psoriasis in the Pediatric Dermatology Unit of Andreas Sygros Skin Hospital, in Athens, Greece. Results A total of 125 children with psoriasis were examined, the male to female ratio was 1.4 : 1 and the peak age of onset was in the 9‐ to 10‐year‐old age group. Only 16% of the patients had a positive family history. Plaque type psoriasis was the most prevalent type at presentation with 56.8% of the children affected, followed by scalp involvement (33.6%). The limbs were the most prevalent site of involvement (70 children, 56%), followed by the body (59 children, 47.2%) and scalp (60 children, 48%) equally affected. Most of the children had <5% of their skin affected by psoriasis (53.2%). Age of onset had no influence on the severity of the disease (P = 0.107), whereas a positive correlation was found with sex and severity of the disease, with male patients being more severely affected (P = 0.008). Family history did not influence the age at presentation (P = 0.68). Topical steroids were used in most commonly followed by keratolytics, calcipotriol, topical tacrolimus and topical pimecrolimus. Conclusion Our study reflects the patterns of presentation of childhood psoriasis in sunny countries like Greece.     

Severe psoriasis: 160 cases

INTRODUCTION: Psoriasis is a frequent dermatosis, its prevalence is estimated of between 1 and 3 p. 100. The severe forms may threaten the functional and life prognosis of patients. PATIENTS AND METHODS: We conducted a retrospective study on 160 cases of severe psoriasis collected between 1990 and 2001. We included patients exhibiting severe psoriasis: pustular, erythrodermic or arthropathic psoriasis, the generalized forms that had developed for more than 6 months, without positive response to treatment and the forms with a PASI greater than 50. RESULTS: The patients' ages ranged from 6 to 85 years with a clear male predominance (96 men, 64 women). Nine familial cases were collected. Erythroderma was noted in 87 cases, pustular psoriasis in 31, generalized psoriasis in 31 and psoriatic rheumatism in 15 (4 of which were associated with pustular psoriasis). Local treatment with topical corticosteroids or a Vitamin D derivative was recommended in respectively 41.8 and 13.75 p. 100 of cases. The administration of general treated relied on methotrexate and was required in 68.75 p. 100 of cases. Progression was usually good, relapses were often noted when treatment was stopped. Four patients died. DISCUSSION: Although the diagnosis of psoriasis is often easy, the severe forms are still difficult to treat. Treatment is complicated, sometimes disappointing and often necessitates heavy and aggressive treatments that require strict surveillance.     

Proactive treatment with calcipotriol reduces recurrence of plaque psoriasis

Topical calcipotriol is a widely used treatment for plaque‐type psoriasis worldwide, and has been shown to improve psoriatic plaques as well as very potent corticosteroids. However, there remains the practical question of whether calcipotriol application should continue on healed pigmentation/depigmentation associated with psoriatic plaques. Therefore, we conducted a pilot clinical study to answer this question. Plaque‐type psoriatic patients not receiving systemic treatment were enrolled and treated with calcipotriol for 8 weeks (stage I) to achieve maximum effect. The patients were then divided into two groups: group A continued to apply calcipotriol to the entirety of the previous lesion (including pigmentation/depigmentation) regardless of whether skin was healed or not, while group B applied calcipotriol to the remaining lesion only. Patients were followed for 12 weeks (stage II) and dates of plaque recurrence were recorded. A total of 29 patients (13 men, 16 women) were enrolled. During stage I, reductions in scores for redness, induration and scale occurred in 40%, 47% and 55% of patients, respectively. After stage II was completed, group A (n = 19) showed a significantly better Kaplan–Meier curve of non‐recurrence than group B (n = 8, P < 0.01). The mean non‐recurrence duration was 76.8 ± 11.8 in group A and 35.0 ± 12.0 in group B. Our study showed that applying topical calcipotriol on seemingly healed psoriatic plaque lesions suppresses recurrence better than applying it only on remaining plaques. This finding may be important for instructing psoriatic patients on topical calcipotriol treatment.     

Successful management of infliximab‐induced generalized pustular psoriasis without therapy discontinuation in a patient with psoriatic arthritis

While infliximab has been shown to be paradoxically associated with the development of pustular psoriasis in patients with rheumatoid arthritis, spondyloaripathies, juvenile idiopathic, and inflammatory bowel disease, there are few cases of pustular psoriasis induced by infliximab in patients with psoriasis. We here present a 55‐year‐old female patient with longstanding plaque psoriasis and psoriatic arthritis who developed generalized pustular psoriasis 1 month after the fifth infusion of infliximab. Given the lack of other side effects and the rapid initial response of the underlying psoriatic arthritis, we opted against discontinuing infliximab therapy, and the sixth infusion of infliximab was administered 10 days ahead of schedule. Topical corticosteroids were added for the management of pustular lesions on initial presentation. One week after the sixth infusion, the pustular psoriatic lesions almost completely disappeared. No recurrence of pustular psoriasis was observed during the 3‐month follow‐up. Our experience shows that pustular lesions associated with infliximab can be successfully managed with topical corticosteroids without discontinuing infliximab therapy or compromising therapeutic benefit seen upon the underlying condition.     

Treatment of psoriatic nails with topical cyclosporin: a prospective,randomized placebo-controlled study

BACKGROUND: Nail involvement is a frequent event in the course of psoriasis causing severe distress. While systemic cyclosporin (CsA) represents a well-established therapy of psoriasis, its topical use is limited by the difficult penetration of the molecule through the skin and the nail because of its highly lipophilic nature. OBJECTIVES: We carried out a prospective randomized placebo-controlled study in order to analyze the effectiveness and tolerability of topical oil-dissolved 70% CsA solution in nail psoriasis. METHODS: Sixteen adult patients with nail psoriasis, divided randomly into two groups of 8 patients (group A and group B), were treated respectively with a 70% maize-oil-dissolved oral CsA solution and maize oil alone. To compare the therapeutic effectiveness, all patients were evaluated, before starting the treatment and after 12 weeks of therapy, by the same dermatologists. The patients were also asked to assess the severity of their nail involvement at baseline and at the end of the treatment. RESULTS: In group A, 3 patients came to a complete resolution of nail lesions and 5 showed a substantial improvement of the overall severity score. In group B, a slight improvement was noted in only 1 patient. All the patients of group A judged positively the results of the therapy, while in group B only 1 patient reported a moderate improvement. CONCLUSION: Our results show that topical therapy with oral CsA solution is a safe, effective and cosmetically highly acceptable treatment modality for nail psoriasis. The ability of CsA to influence keratinocyte proliferation and T-cell lymphokine release, reducing the cornification of the upper layers of the epidermis, may prevent the typical alterations observed in nail psoriasis.