Topical Halobetasol Propionate in the Treatment of Plaque Psoriasis

Halobetasol propionate (HP) 0.5% ointment and cream are class I topical corticosteroids. We review the efficacy and tolerability of HP for treatment of plaque psoriasis in the English language literature. The efficacy of HP ointment and cream is consistently superior to other super-potent topical corticosteroids. Local adverse events associated with topical HP are similar to those experienced with other super-potent corticosteroids. Combination therapy with calcipotriene (calcipotriol) and tazarotene appears to be superior to monotherapy with topical HP.     

Receptor-Selective Retinoids for Psoriasis

Topical and oral retinoids have been successfully used in antipsoriatic therapy over the last 50 years. Development of more selective agents has led to an improved efficacy and safety profile. The first topical receptor-selective retinoid to be approved for the treatment of plaque psoriasis is tazarotene. Topical tazarotene displays an onset of action and efficacy similar to those of other established antipsoriatic agents. Common adverse events of this agent such as pruritus, burning, local skin irritation, and erythema are limited to the skin and generally mild or moderate in severity. Although effective as monotherapy, evidence is accumulating that combining topical tazarotene with other established antipsoriatic therapies results in enhanced efficacy and reduced adverse events. In particular, concomitant use of topical tazarotene with a mid-potency or high-potency corticosteroid in the treatment of psoriatic plaques enhances efficacy and reduces the risk of corticosteroid-induced skin atrophy. Combination of phototherapy with tazarotene accelerates the clinical response and diminishes the cumulative UVB or psoralen plus UVA (PUVA) exposure load. Recently, an oral form of tazarotene has been developed. The results of completed phase III clinical trials of this agent indicate a beneficial effect in moderate to severe plaque psoriasis. Adverse events are generally of mild severity, and most of those observed, such as cheilitis and dry skin, are typical of hypervitaminosis A. Of note, oral tazarotene appears not to be associated with other adverse events that are typical of oral retinoids, including hypertriglyceridemia and hypercholesterolemia. However, since head-to-head trials with acitretin (the only retinoid currently approved for systemic therapy) have not been conducted, it is unclear whether tazarotene is any safer or more effective than acitretin. Moreover, the major drawback of oral tazarotene is teratogenicity, which may limit its use in female patients. Further studies evaluating long-term clinical outcomes with oral tazarotene and its use in combination therapies are awaited.     

Combination therapy with tazarotene plus a topical corticosteroid for the treatment of plaque psoriasis

Although tazarotene monotherapy is generally efficacious and well tolerated, studies show that both the efficacy and the tolerability of tazarotene therapy can be further improved when it is used in combination with certain topical corticosteroids. The studies reported here evaluate the usefulness of two potential combination regimens. In one regimen, a corticosteroid is added to tazarotene treatment. In the other regimen, corticosteroid treatment alternates on a daily basis with tazarotene treatment. The results of the first study, which involved 300 patients, showed that additive combination therapy using tazarotene plus a mid- or high-potency topical corticosteroid significantly increased the percentage of plaques achieving treatment success at the end of the treatment period, compared with tazarotene plus placebo (91% and 95% vs. 80%, respectively; P  < 0.05 for both). Similarly, tazarotene plus a mid- or high-potency topical corticosteroid reduced the incidence of patient withdrawals compared with tazarotene plus placebo (5.5% and 9.6% vs. 13.3%). The results of the second study, which involved 398 patients, showed that a combination regimen that alternates between tazarotene and a high-potency topical corticosteroid treatment each day, significantly increased the treatment success rate compared with regimens using tazarotene alternating with a mid-potency corticosteroid or placebo (75% vs. 55% and 54%, respectively, at the end of the treatment period; P  < 0.05 for both). In addition, there was a trend towards a lower incidence of treatment-related adverse events as corticosteroid potency increased (from 42% with tazarotene plus placebo to 36%, 32%, and 31% with tazarotene plus the low-, mid-, and high-potency corticosteroid, respectively). Both treatment regimens are potentially useful and offer a rational approach to optimizing the efficacy and tolerability of tazarotene treatment for plaque psoriasis.     

A clinical evaluation of tazarotene 0.1% gel, with and without a high- or mid-high-potency corticosteroid, in patients with stable plaque psoriasis

BACKGROUND: Several clinical trials have established the benefit of using a topical corticosteroid in conjunction with tazarotene gel in the treatment of plaque psoriasis. However, there is little information comparing the relative benefits of different corticosteroids, or different formulations of corticosteroids, when used adjunctively with tazarotene. OBJECTIVE: This study was designed to compare the clinical benefits achieved with each of six commonly prescribed high- or mid-high-potency corticosteroid creams and ointments applied in conjunction with tazarotene 0.1% gel in the treatment of patients with stable plaque psoriasis. METHODS: A 12-week, multicenter, investigator-masked, randomized, parallel-group study was performed with more than 200 patients who were randomly assigned to regimens of tazarotene 0.1% gel alone, tazarotene plus a high-potency topical corticosteroid (fluocinonide 0.05% ointment, mometasone furoate 0.1% ointment, or diflorasone diacetate 0.05% ointment), or tazarotene plus a mid-high-potency topical corticosteroid (betamethasone dipropionate 0.05% cream, fluticasone propionate 0.005% ointment, or diflorasone diacetate 0.05% cream). All medications were to be applied once daily: corticosteroids in the morning, tazarotene gel in the evening. At assessment visits, physicians made an overall evaluation of the patient's psoriasis and graded global improvement, plaque elevation, scaling, erythema, and pruritus. Patients also rated their treatment in terms of efficacy, tolerability, and satisfaction. RESULTS: The best-performing steroid was betamethasone dipropionate 0.05% cream (a mid-high-potency steroid), followed by mometasone furoate 0.1% ointment (a high-potency steroid) and diflorasone diacetate 0.05% ointment (a high-potency steroid). Maximum improvements were achieved within 8 weeks. The best-tolerated regimen was tazarotene plus mometasone furoate 0.1% ointment and the optimal balance between efficacy and tolerability was achieved with this regimen. CONCLUSION: Some steroids are considerably more effective than others in optimizing the efficacy and tolerability of tazarotene therapy. With a suitable combination regimen, the duration of initial therapy (before maintenance therapy is started) need not be prolonged.     

A systematic review of adverse effects associated with topical treatments for psoriasis

Mild to moderate psoriasis is a disease that can often be treated with topical medications. The diversity of topical therapies and their disparate side effects complicates treatment planning. Our purpose is to compare the rates of adverse events associated with different topical psoriasis treatments. A review of medical literature from 1996 to March, 2002 was conducted using guidelines set by QUORUM statement criteria. In monotherapy studies, corticosteriods caused fewer adverse reactions compared to vitamin D analogues and tazarotene. In combination studies adverse event rates were higher than in monotherapy studies, except for the combination of topical steroid and calcipotriene which decreased irritation. Irritant contact dermatitis was the main side effect with vitamin D analogues, tazarotene, dithranol or coal tar, while side effects of topical corticosteriods included headache, viral infection and skin atrophy. Topical agents for psoriasis are usually well-tolerated without severe side effects. Formulating a patient's medication regimen should take into account the needs for short-term management and long-term control of psoriasis. Since clearance is not a realistic expectation, reasonable goals should be set as excessive use of topical treatments may increase the risk of both cutaneous and systemic side effects.     

Factors impacting the combination of topical corticosteroid therapies for psoriasis: perspectives from the international psoriasis council

Corticosteroids are the mainstay of topical therapies for the treatment of mild to moderate psoriasis. Selection of vehicle, concentrations of corticosteroid and coadministered medications, and frequency of administration are critical factors that enhance bioavailability of topical corticosteroids. Topical corticosteroids are commonly used as polytherapy and combination therapy with other agents, such as salicylic acid, vitamin D analogues and tazarotene. Combinations are selected for the ability to enhance efficacy while minimizing corticosteroid‐related side‐effects, such as cutaneous atrophy. New, innovative products such as sprays, foams and nail lacquers provide opportunities to tailor treatment for individuals, which promotes patient adherence to medications. This review covers features of topical corticosteroid formulations that affect bioavailability, efficacy and safety when used as monotherapy and in combination with other agents for the treatment of mild to moderate psoriasis.     

Combination phototherapy of psoriasis with narrow-band UVB irradiation and topical tazarotene gel

BACKGROUND: Narrow-band UVB (311 nm) phototherapy offering an emission spectrum closely conforming to the peak of the action spectrum for clearing psoriasis has significantly improved phototherapy for psoriasis. Because the majority of the commonly used topical therapies in treatment of psoriasis have limitations, a need for new topical agents remains. Tazarotene has been shown to be efficacious in plaque-type psoriasis. Combination of narrow-band UVB with topical agents has been shown to enhance efficacy of both treatment modalities. OBJECTIVE: We attempted to evaluate the efficacy of narrow-band UVB phototherapy in combination with topical tazarotene. METHODS: Ten patients with stable plaque psoriasis were treated with narrow-band UVB. In addition, topical tazarotene 0.05% was applied once daily to one side of the body. The follow-up period was 4 weeks. Efficacy was assessed separately for both body halves by means of a modified Psoriasis Area and Severity Index (PASI). RESULTS: Both treatment modalities notably reduced the PASI scores with values being significantly lower in skin areas treated with narrow-band UVB phototherapy in combination with topical tazarotene. CONCLUSION: The addition of tazarotene to narrow-band UVB phototherapy promotes more effective, faster clearing of psoriasis compared with UVB (311 nm) monotherapy.     

Optimizing treatment with topical tazarotene

Tazarotene is a receptor-selective retinoid, which is efficacious in the treatment of patients with psoriasis, acne vulgaris, and photoaging. It normalizes keratinocyte differentiation, reverses keratinocyte hyperproliferation, and has anti-inflammatory effects. Clinical studies have shown that tazarotene 0.1% gel has greater comedolytic activity than tretinoin (Retin-A 0.025% gel, Retin-A Micro 0.1%) and adapalene (Differin) 0.1% gel. Although it is efficacious as monotherapy, tazarotene is more commonly used as part of combination therapy with a topical antibacterial in patients with acne vulgaris, and with a mid- or high-potency topical corticosteroid or with phototherapy in patients with psoriasis. Combination therapy enhances efficacy and tolerability. Tazarotene 0.1% gel, used in combination with mometasone furoate 0.1% cream, was shown in psoriasis clinical trials to be more efficacious than calcipotriene (calcipotriol) ointment used twice daily, or mometasone furoate 0.1% cream used twice daily. Use of tazarotene in conjunction with broad band UVB, narrow band UVB or bath psoralens + UVA (PUVA) results in greater efficacy than with phototherapy alone. Tazarotene should not be administered during pregnancy or in women who are not practicing adequate contraception. Adverse events consist primarily of irritation, peeling, erythema, dryness, burning, and itching. They are most common during the first 1-2 weeks of therapy and can be minimized with use of the cream formulation, alternate day application, short contact therapy, mild cleansers, and combination therapy.     

Efficacy and safety of combinations of first‐line topical treatments in chronic plaque psoriasis: a systematic literature review

Background Most psoriasis patients suffering from mild to moderate disease are treated with first‐line topical treatments, including corticosteroids, vitamin D analogues, topical retinoids and calcineurin inhibitors. Although evidence‐based guidelines on combinations are lacking, the majority of patients will be treated with combinations of these popular topicals at some point during their life‐long treatment. Objectives We intended to systematically review all available literature on the efficacy and safety of combinations of first‐line topicals in chronic plaque psoriasis, and ultimately, to propose recommendations for combined regimens concerning first‐line treatments. Methods Databases used as data sources were PubMed, EMBASE and the Cochrane Controlled Clinical Trial Register. According to standardized procedures, literature searches were performed and a level of evidence was determined. Results In total, 2918 publications on topical combination therapy were revealed, of which 45 articles on first‐line combinations were included. The combination of potent and superpotent corticosteroids with vitamin D analogues provides an improvement of psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients. The two‐compound product permits once‐daily treatment and therefore is a good solution for chronic plaque psoriasis including scalp psoriasis. Combinations of corticosteroids, with tazarotene or with calcineurin inhibitors do not provide an advantage above corticosteroid monotherapy. Conclusion The combination of potent corticosteroids with calcipotriol has been studied most extensively and should be regarded as an efficacious and safe treatment option with the two‐compound products as the most practical solution.     

Instrumental evaluation of retinoid-induced skin irritation

Background/purpose Retinoids like tazarotene are approved for the treatment of chronic plaque psoriasis. In the beginning of topical retinoid therapy, 15–20% of the patients suffer from mild to moderate adverse reactions with burning and erythema. The aim of the study was to find predicative parameters of the individual irritative potential and to suggest options to reduce these initial irritations. Methods Twenty in-patients with different skin types (1 + 2: 11, 3 + 4: 9), with chronic plaque psoriasis were included in this open study. In each patient, 7 randomized plaques on the forearm were treated for 14 days on different ways: test area 1: morning (m) and evening (e) placebo, test area 2: placebo (m) and tazarotene 0.05% (e), test area 3: placebo (m) and tazarotene 0.1% (e), test area 4: calcipotriol (m) and calcípotriol (e), test area 5: mometasone furoate (m) and tazarotene 0.05% (e), test area 6: mometasone furoate (m) and tazarotene 0,1% (e), test area 7: placebo (m) and tazarotene in increasing concentrations (e), test area 8: healthy skin for control. Before and after therapy, skin barrier function, blood flow and plaque thickness in 20-MHz sonography were assessed in different test areas intraindividually by non- invasive biophysical measurements. Results After 14 days of therapy, tazarotene 0.05% and 0.1% produced a stronger increase of laser Doppler flow in patients with skin type 1 and 2 than in patients with skin type 3 and 4. When using the combination therapy of tazarotene and mometasone, the laser Doppler flow was significantly lower than in tazarotene as monotherapy. 20-MHz-ultrasound showed a significant decrease in the thickness of the echopoor band in all topical therapy regimens compared to placebo. Patients of skin type 1 and 2 reached a higher density of the dermis than patients of skin type 3 and 4, meaning a stronger decrease of inflammatory infiltration and acanthosis. Conclusion Adapting retinoid therapy to the patient's skin type can reduce the initial irritative side-effects. During the first days, patients with skin type 1 or 2 should add a medium potency corticosteroid. Stronger skin irritation caused by tazarotene therapy increases therapy effects.     

Investigator-masked comparison of tazarotene gel q.d. plus mometasone furoate cream q.d. vs. mometasone furoate cream b.i.d. in the treatment of plaque psoriasis

Seventy‐three patients with stable plaque psoriasis entered an investigator‐masked trial comparing once‐daily tazarotene 0.1% gel plus once‐daily mometasone furoate 0.1% cream with twice‐daily mometasone furoate 0.1% cream. The aim of the study was to determine whether tazarotene and mometasone furoate act synergistically –‐ a previous study showed that tazarotene plus mometasone furoate offered greater efficacy than tazarotene alone, and this study investigated whether tazarotene plus mometasone furoate also offered greater efficacy than mometasone furoate alone. The patients had psoriasis affecting up to 20% of their total body surface area, with at least moderate plaque elevation. Washout periods were: 2 weeks for UVB phototherapy or topical antipsoriatic therapies; 4 weeks for psoralen plus UVA (PUVA) therapy or systemic antipsoriatic drugs other than retinoids; and 8 weeks for oral retinoids. All patients gave written informed consent and the study was conducted in compliance with the ethical standards of the governing institutional review boards and the Declaration of Helsinki. Patients were treated for up to 12 weeks. If they achieved clearance by week 4, or at least 50% global improvement by week 12, they were entered into the 12‐week no‐treatment follow‐up phase. Patients were evaluated every 4 weeks in terms of percentage global improvement, plaque elevation, scaling, erythema, and pruritus. They also rated the efficacy of their own treatment (as very effective, effective, neutral, ineffective, or less effective) and the duration of improvement in their psoriasis (as much better, better, somewhat better, indifferent, or worse than that achieved with other topical medications they had used in the past). The two regimens were compared by analysis of variance, with the last recorded score for any patient who discontinued prematurely (due to lack of efficacy, adverse events, or disease flare) being carried forward to all subsequent visits.     

A comparison of psoralen plus ultraviolet A (PUVA) monotherapy,tacalcitol plus PUVA and tazarotene plus PUVA in patients with chronic plaque-type psoriasis

BACKGROUND: Numerous studies have shown that the additional administration of topical or systemic antipsoriatic agents might serve as an effective means to increase the efficacy of photochemotherapy [psoralen plus ultraviolet (UV) A (PUVA)] for psoriasis. OBJECTIVES: To compare the therapeutic response to tacalcitol plus PUVA, tazarotene plus PUVA and PUVA monotherapy in patients with chronic plaque-type psoriasis. In addition, we also assessed the duration of remission induced by each regimen and the tolerability of the two combination treatments. METHODS: Thirty-one patients with chronic plaque-type psoriasis were included in this observer-blinded, intrapatient comparison trial. PUVA treatment was given four times weekly. Additionally, tacalcitol ointment and 0.1% tazarotene gel were applied separately on two target areas once daily in the evening. At the onset of therapy and every 2 weeks thereafter the response to treatment was determined by the Psoriasis Severity Index score, which assesses the degree of erythema, infiltration and scaling of the psoriatic lesions. After complete or near complete clearing patients were followed-up until relapse. RESULTS: Twenty-four patients completed the study. The treatment requirements to induce complete or near complete clearing were significantly lower for both combination treatments than for PUVA monotherapy (P < 0.01). The median cumulative UVA dose and number of exposures were 30.6 J cm-2 (95% confidence interval, CI 22.5-71.2) and 14 (95% CI 11-16) for tacalcitol plus PUVA, 32.3 J cm-2 (95% CI 22.5-73.8) and 14 (95% CI 11-19) for tazarotene plus PUVA, and 37.0 J cm-2 (95% CI 29.5-83.9) and 16 (95% CI 14-22) for PUVA monotherapy. No difference between the three regimens was observed with regard to duration of remission. Adverse reactions occurred more often with 0.1% tazarotene than with tacalcitol but were in general mild and completely reversible upon using a lower concentration of 0.05% tazarotene. CONCLUSIONS: Tacalcitol ointment and tazarotene gel are both comparably effective in improving the therapeutic result of PUVA therapy in patients with chronic plaque-type psoriasis. Besides accelerating the treatment response, both agents, by virtue of their UVA dose-sparing effect, might also help to reduce possible long-term hazards of PUVA treatment.     

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.     

Tazarotene gel with narrow-band UVB phototherapy: a synergistic combination in psoriasis

Background: Narrow-band UVB (NB-UVB) has been shown to be one of the most effective treatment modalities for psoriasis. Tazarotene, a known effective anti-psoriatic modality, when combined with NB-UVB may enhance the therapeutic success.Objective: To study clinical efficacy and safety of combination of NB-UVB with topical tazarotene 0.05% gel in psoriasis.Method: Thirty patients with plaque psoriasis having symmetrical lesions were enrolled for 12 weeks. All patients were instructed to apply tazarotene gel on target plaque on left side of body once daily. In addition, the whole body was irradiated with NB-UVB twice weekly. Efficacy was assessed by target plaque scoring and number of treatment sessions for clearance.Result: Our study resulted in 3 key findings: Firstly, therapeutic efficacy of NB-UVB was enhanced by addition of tazarotene. This enhanced efficacy was more apparent in decreasing scaling and thickness as compared to decrease in erythema. Secondly, combination therapy showed faster clearance of target plaques, with reduction in mean number of treatment sessions. Thirdly, mean cumulative NB-UVB dose needed to achieve clearance of target plaques was significantly reduced with combination therapy.Study limitations: The study was not randomized or controlled, but an open-label trial. The study period was relatively short, i.e., 12 weeks, without any follow-up period.Conclusion: Tazarotene gel significantly enhances the therapeutic efficacy of NB-UVB irradiation with faster clearance and without serious side effects.     

Calcitriol ointment and clobetasol propionate cream: a new regimen for the treatment of plaque psoriasis

For psoriasis therapy, topical derivatives of vitamin D3 represent a versatile option: they can be used either alone or in combination with other agents such as topical corticosteroids. In this two-phase parallel-group study, the naturally occurring vitamin D3 analogue, calcitriol, was compared with the vitamin D analogue calcipotriol in 125 patients with chronic plaque-type psoriasis. The proposed treatment regimen was an initial bitherapy for 2 or 4 weeks, with clobetasol propionate 0.05% cream, a super potent topical corticosteroid applied in the morning and either calcitriol 3 mug/g ointment or calcipotriol 50 mug/g ointment applied in the evening, followed by monotherapy with either calcitriol or calcipotriol applied twice daily until endpoint week 12. Efficacy evaluations (global assessment of improvement, PASI and body surface area (BSA) affected) showed no significant differences between the two regimen groups at the primary endpoints (week 2 and week 12) or at any interim points. At week 2 the investigator's global assessment showed clinical success (psoriasis markedly improved, almost clear or clear) for more than 50% of the patients in both groups and for 48 (79%) and 56 (88%) patients, respectively in the calcitriol and calcipotriol regimen group at week 12. Least-square means analysis of PASI indicated the calcitriol regimen to be equivalent to the calcipotriol regimen. There were no significant differences between the two groups with regards to cutaneous safety or to incidence of adverse events. The present study shows that for the treatment of mild to moderate plaque psoriasis calcitriol 3 mug/g ointment can provide a safe and effective alternative to calcipotriol 50 mug/g ointment while being administered within a regimen based on a bitherapy with corticosteroids followed by a vitamin D3 maintenance monotherapy.     

他扎罗汀凝胶联合地奈德乳膏治疗寻常性斑块状银屑病的疗效观察

目的探讨他扎罗汀凝胶联合地奈德乳膏治疗斑块状银屑病的疗效。方法将84例患者随机分为他扎罗汀凝胶组、地奈德乳膏组和联合治疗组。联合治疗组晚上外用他扎罗汀1次,早上再用地奈德乳膏1次;地奈德组单用地奈德乳膏,2次/d;他扎罗汀组则仅晚上外用他扎罗汀1次,疗程均为4周。结果地奈德和联合治疗组的有效率分别为71.43%和64.29%,高于他扎罗汀组的35.71%(P<0.05),但联合组和地奈德组间差异无统计学意义。3组患者复发率依次为地奈德组25.00%、他扎罗汀组20.00%、联合治疗组11.11%,3组间比较差异无统计学意义(P>0.05)。观察期间均未发生严重不良反应。结论地奈德治疗寻常性斑块状银屑病疗效优于他扎罗汀,两者联合应用可减少激素的用量,减轻了药物的局部不良反应,且可能降低银屑病的复发率,使用安全。     

Per-gram cost of medication is by itself a poor indicator for comparing costs of different psoriasis treatments: a retrospective cohort study of the cost of psoriasis treatment with topical corticosteroids versus topical calcipotriene

BACKGROUND: New treatments are available for psoriasis that complement or replace the use of topical corticosteroids. OBJECTIVE: The purpose of this article is to assess the relative overall cost difference between regimens based on topical steroids and those using the nonsteroidal anti- psoriasis medication, topical calcipotriene. METHODS: Retrospective data on the cost of therapy of psoriasis were attained through analysis of claims from a national pharmaceutical-and-medical-visit claims-database. Episodes of psoriasis treatment were defined and analyzed for patients whose therapy was initiated with either topical calcipotriene or topical corticosteroids of different potency classes. RESULTS: The average medication cost per episode was greater for topical calcipotriene ($111/episode) compared to ultra-high potency ($70/episode), high potency ($57/episode), mid potency ($47/episode), and low-potency, ($75/episode) topical corticosteroids (p <.05). The average total cost of therapy for the topical calcipotriene regimen ($218) fell within the range for the cost of therapy for topical steroid base regimens ($197 to $457); there were no significant differences in the total cost of therapy between topical calcipotriene monotherapy and other treatment groups. CONCLUSION: The per-gram cost of medication is by itself a poor indicator for comparing the cost of different psoriasis treatment regimens. Given the greater safety and efficacy of combination regimens in terms of both short-term improvement and long-term control, initiating psoriasis treatment with a combination regimen of topical calcipotriene combined with an ultrapotent corticosteroid appears to be the most cost-effective approach to psoriasis treatment.     

Topical tazarotene vs. coal tar in stable plaque psoriasis

Background. The efficacy of topical tazarotene has not previously been compared with the conventional topical treatment of crude coal tar (CCT) in stable plaque psoriasis. Aim. To assess the comparative efficacy and tolerability of topical tazarotene 0.1% gel and CCT 5% ointment in stable plaque psoriasis. Methods. In this nonblinded side‐to‐side comparison study, patients with chronic stable plaque psoriasis, who had bilaterally symmetrical plaques on the limbs, applied 0.1% tazarotene gel on the right side and 5% CCT ointment on the left side once daily for 12 weeks followed by an 8‐week treatment‐free follow up period. Severity of psoriatic lesions and response to treatment was evaluated by scoring erythema, scaling and induration (ESI). Results. Of 30 patients recruited, 27 could be assessed. In the per‐protocol analysis, the mean percentage reduction in ESI score at the end of the treatment period was 74.15% ± 9.43 and 77.37% ± 10.93 with tazarotene and CCT, respectively (P > 0.05). A reduction in ESI score of > 75% was seen in 11 (40.74%) and 16 (59.26%) patients with tazarotene and CCT, respectively, at the end of 12 weeks. Side‐effects were seen in 48.14% of patients treated with tazarotene, but in no patient treated with CCT. Conclusions. Tazarotene 0.1% gel has comparable clinical efficacy to CCT 5% ointment. CCT ointment remains a cost‐effective therapy for plaque psoriasis.     

Combination of calcipotriene (Dovonex) ointment and tazarotene (Tazorac) gel versus clobetasol ointment in the treatment of plaque psoriasis: a pilot study

BACKGROUND: Both calcipotriene and tazarotene have been shown to be effective in the treatment of psoriasis. No study has evaluated the effect of using both agents simultaneously. OBJECTIVE: Our purpose was to evaluate the effectiveness of combination treatment of psoriasis with calcipotriene ointment and tazarotene gel by comparing them with clobetasol ointment, a class I topical corticosteroid. A secondary objective was to evaluate the clinical compatibility of applying both agents at the same time. METHODS: This pilot study was a prospective, single-center, open-label, right/left comparison of 28 lesion pairs in 15 patients. It consisted of a 2-week treatment phase, followed by a 4-week post-treatment observation phase. RESULTS: All 15 patients completed the treatment phase of the study. At the end of the active treatment phase (end of week 2), calcipotriene- and tazarotene-treated lesions showed nearly identical reductions in scaling (P =.93), plaque elevation (P =.76), and overall lesional severity scores (P =.29) compared with their matched clobetasol-treated counterparts. Erythema improved significantly more in clobetasol-treated lesions (P <.05) during the treatment period, but differences became statistically insignificant during the post-treatment period (;P =.20). No patients had significant irritation from the treatments. During the post-treatment phase (weeks 3-6), all lesions worsened; plaque elevation returned somewhat more rapidly in calcipotriene- and tazarotene-treated lesions (P <.01), whereas changes in scaling, erythema, and overall lesional severity were not significantly different between the two treatment groups (P >.05). CONCLUSION: The nonsteroid combination of twice-daily calcipotriene ointment and once-daily tazarotene gel was not statistically different from twice-daily application of the class I corticosteroid clobetasol ointment in reducing psoriatic scaling, plaque elevation, and overall lesional severity over a 2-week period. There does not seem to be any chemical incompatibility between calcipotriene ointment and tazarotene gel that is clinically significant.     

In vitro compatibility of tazarotene with other topical treatments of psoriasis

Tazarotene is the first receptor-selective retinoid indicated for the topical treatment of plaque psoriasis. It is being used clinically in combination with other topical antipsoriatic treatments, although its stability in the presence of these products has not been examined extensively. This study examines the compatibility of tazarotene 0.05% gel with 17 other topical products used in the treatment of psoriasis, assessed over a 2-week period. Tazarotene showed minimal degradation (<10%) at 0, 8, 24, and 48 hours after compounding with each of the 17 products. In addition, after 1 and 2 weeks, degradation of tazarotene remained less than 10% for 15 of the 17 products tested. Tazarotene appeared to have minimal impact on the stability of the other products. These results suggest that tazarotene gel can be successfully coprescribed with a range of commonly used topical psoriasis treatments without adversely affecting the chemical stability of either agent.