Systemic Antipsoriatic Drugs Research Articles

Association of Elevated ASO Titer with Plaque and Guttate Psoriasis

Objectives: To determine the association of elevated ASO titer with plaque and guttate psoriasis. Study Design: Case control study. Place and Duration: Department of Dermatology, Shaheed Mohtrama Benazir Bhutto Medical University (SMBBMU), Larkana during from 22nd January 2018 to 21st July 2018 Materials & Methods: A total of 30 patients with plaque or guttate psoriasis and 30 controls, 20 to 60 years of age of either gender were included. Patients taking systemic anti-psoriatic drugs, CRF and erythroderma were excluded. After this throat swabs were taken and pathogenic organism was identified by gross colony morphology and types of hemolysis on culture media. β-hemolysis indicated growth of Streptococcus pyogens. Antistreptolysin O titer (ASO titer) was measured and titer >200 IU/ml was taken as elevated. Results: Mean age was 40.92 ± 10.62 years. Out of 60 patients, 40 (66.67%) were males and 20 (33.33%) were females with male to female ratio of 2:1. Frequency of elevated ASO titer in patients with plaque and guttate psoriasis was found in 13 (43.33%) and in 04 (13.33%) controls with p-value of 0.014 and odds ratio of 2.97. Conclusion: This study concluded that concluded that there is positive association of elevated ASO titer with plaque and guttate psoriasis. Keywords: Psoriasis, Throat Infection, ASO Titer

In psoriasis treatment, greater improvement in skin severity predicts greater improvement in nail severity

Background Nail are important for both function and esthetic appearance and although they represent a small body surface area, dermatologic disorders affecting the nails can have a detrimental effect to the patient. Deciding on the best systemic antipsoriatic drug to treat nail psoriasis can be difficult due to the lack of nail data on their Food and Drug Administration-approved labels, as well as the variety of scoring systems used for nail psoriasis. Methods We performed a literature review and included randomized control trials or articles based on randomized control trials for different systemic antipsoriatic drugs. Only articles and studies utilizing Nail Psoriasis Severity Index (NAPSI) or target NAPSI as outcome measures were included. Data was taken directly from articles, directly from clincaltrials.gov or directly from data on file at various pharmaceutical companies. Results Data for NAPSI and PASI were collected for 10 antipsoriatic drugs including three oral medications and seven biologic agents. We found that NAPSI or target NAPSI was strongly predicted based on the change in PASI and duration of treatment (R 2 = 0.71, p = .0002). PASI alone (R 2 = 0.52, p = .001) and duration alone (R 2 = 0.21, p = .07) predict NAPSI response. Conclusion According to this model, there is a relationship between skin and nail response, with improvement in nails correlating with improvement in skin and longer duration of treatment.

Psoriasis in Patients With Active Lung Cancer: Is Apremilast a Safe Option?

Concomitant cancers in psoriasis patients often pose significant limitations in treatment decision. In contrast to the majority of the available systemic antipsoriatic drugs, apremilast is not contraindicated in case of previous or concomitant malignancy [1]. We report a patient with psoriasis and lung adenocarcinoma who completely responded to apremilast. The patient provided written informed consent for the data reported in the current manuscript.

Design of an Algorithm for Automated, Computer-Guided PASI Measurements by Digital Image Analysis

The Psoriasis Area and Severity Index (PASI) is the most accepted method for psoriasis severity scoring. However, a prominent level of subjectivity and a low intra- and inter-rater reproducibility was reported. Therefore, an accurate and reproducible measure of psoriasis severity is needed, especially in the setting of registration studies for systemic anti-psoriatic drugs. Herein we describe a robust, user-friendly, computer-guided technology that allows for automated PASI measurements after total body imaging and digital image analysis. For this purpose, a novel image processing software for PASI calculations was developed, which was combined with a commercially available, automated image capturing system. Our data shows, that the software was able to accurately calculate the proportion of psoriatic skin surface as well as the severity of erythema, induration, and desquamation by anatomic region. In a pilot clinical validation the time-efficient technology showed a high reproducibility and high levels of agreement to results attained by PASI-trained physicians. Therefore, automated computer-guided PASI measurements hold the promise of significantly reducing the physicians' workload while ensuring a high level of reproducibility and standardization.

Intestinal microbiota profiling and predicted metabolic dysregulation in psoriasis patients.

The intestinal microbiota has been known to involve in obesity and host immune response. We aimed to investigate the intestinal microbiota and potential genetic function in relation to clinical presentation in psoriasis patients. Faecal microbiota and predicted genetic function inferred from high-throughput 16S ribosomal RNA sequencing were analysed between psoriasis (n=32) and age-, gender- and body mass index (BMI)-matched non-psoriasis subjects (n=64), from a referral medical centre. The correlation between altered microbiota and disease activity, arthritis and systemic anti-psoriatic drugs was also investigated. We observed a distinct faecal microbial community structure in psoriasis patients, with an increased abundance of phylum Firmicutes and decreased abundance of phylum Bacteroidetes, across different subgroup of subjects. Ruminococcus and Megasphaera, of the phylum Firmicutes, were the top-two genera of discriminant abundance in psoriasis. A number of functional genes and metabolic pathways involving bacterial chemotaxis and carbohydrate transport were predicted over-represented, whereas genes related to cobalamin and iron transport were predicted under-represented in faecal microbiota of psoriasis patients. The distinct faecal microbial composition in psoriasis might be associated with altered transport of carbohydrate, cobalamin and iron, as well as chemotaxis.

Use of topical antipsoriatic drugs in Denmark: a nationwide drug utilization study

The reported real-life use of prescribed topical antipsoriatic drugs is conflicting and based on heterogeneous data sources. To describe the utilization of topical antipsoriatic drugs among patients with psoriasis in Denmark. A drug utilization study was performed based on nationwide Danish health registry data. We identified patients who received a first-time hospital diagnosis of psoriasis and redeemed at least one topical drug prescription in the period 2005-2015 (n=7743). Patients were followed for 3years from the time of diagnosis. Use of topical and systemic antipsoriatic drugs was described, specified by the type of treatment. The total use of topical drugs was divided between corticosteroids with calcipotriol (31%), calcipotriol (6·5%), very potent corticosteroids (24%), potent corticosteroids (30%), moderate corticosteroids (7·2%) and corticosteroids with antimicrobials (1·6%). There was a 19% reduction in the overall use of topical drugs during the study period. Use increased around the time of diagnosis and the majority of patients redeemed more than two packages of topical drugs during the first year after being diagnosed. Regional differences in patients' use of topical drugs varied considerably. The distribution of use of topical drugs was uneven, with a minority of all patients (25%) using 70% of the total amount of topical treatment. There was a 70% increase in the use of methotrexate over the study period. Biologics were used by up to 6%. The study provides further evidence that the use of topical antipsoriatic drugs shows considerable heterogeneity over time and regional practices, and differences between patients.

Plasma alpha-2-macroglobulin level in moderate to severe psoriasis

Psoriasis is a T-cell mediated chronic inflammatory diseases where pro-inflammatory mediators are involved in its pathogenesis. Alpha-2-macroglobulin (α-2M) is a panproteinase inhibitor having unique clearing role of different cytokines. This study was conducted on 30 patients with moderate to severe psoriasis to see the plasma level of α-2M and was compared with the normal healthy controls. Patients who were already selected for systemic treatment (methotrexate) and consented for routine blood test for monitoring at baseline and 12 weeks after treatment were enrolled along with 10 healthy controls. The venous blood (5 mL) was collected and the plasma alfa-2 macroglobulin was estimated using the enzyme-linked immunosorbent assay. The mean plasma α-2M level was 3.0 ± 0.4 g/L among the normal healthy persons, and 2.8 ± 0.7 g/L among the untreated patients of psoriasis (p>0.05). Its level among the patients with psoriasis after systemic antipsoriatic drugs was 2.8 ± 0.6 g/L which was not significantly different from the baseline level (p>0.05). The study shows that the plasma α-2M level in psoriasis is not different comparing with normal healthy persons.

Algorithm to select optimal systemic anti-psoriatic drugs in relation with patients' Psoriasis Area and Severity Index score for plaque psoriasis.

This study sought to develop a therapeutic algorithm for selecting the optimal systemic drugs to treat moderate to severe psoriasis, based on the patient's Psoriasis Area Severity Index (PASI) score. Data from 191 patients undergoing treatment for plaque psoriasis were retrospectively analyzed. Pre- and post-treatment PASI scores were compared across patients treated with acitretin of retinoic acid (RA; n = 95), methotrexate (MTX; n = 41) or cyclosporin A (CsA; n = 55). The PASI score improvement was examined at weeks 4 (primary end-point) and 12 (secondary end-point). MTX and CsA had a higher global therapeutic efficacy, with more patients exhibiting a marked improvement (≥75% improvement in PASI [PASI 75]) at week 12 with MTX (56.1%, P = 0.028) and CsA (54.5%, P = 0.025) than RA (35.8%). Multivariate analysis adjusting for confounders produced consistent results (P = 0.026). For patients with severe psoriasis (PASI >12), the PASI 75 response was higher with CsA (55.6%) than RA (31.5%) (P = 0.023) at week 4 and higher with MTX (57.1%, P = 0.029) and CsA (61.5%, P = 0.017) than RA (21.7%) at week 12. Because RA is a standard systemic drug, the RA group was divided into two subgroups based on the PASI 50 response at week 12. Marked or moderate improvement (PASI ≥50) with RA was observed in patients with a pretreatment PASI score less than 14. Thus, oral RA is recommended as a first-line drug for patients with PASI of less than 14, and MTX or CsA are recommended for patients with PASI of 14 or more.

Metabolic syndrome in untreated patients with psoriasis: case‐control study

Previous studies have shown a higher prevalence of metabolic syndrome in patients with psoriasis compared to controls. However, little attention has been paid to the effect of systemic anti-psoriatic drugs on the metabolic syndrome. The aim of this study was to investigate the association between psoriasis and the metabolic syndrome, by comparing untreated patients with psoriasis and population based control. We conducted a hospital-based case-control study that included 122 untreated patients with plaque psoriasis and 122 age- and gender-matched controls. There was no significant difference in the prevalence of the metabolic syndrome between the patients with psoriasis (24.6%) and the controls (22.9%) (OR 1.095, 95% CI 0.607-1.974). Among the components of the metabolic syndrome only hypertriglyceridemia and abdominal obesity were associated with psoriasis. The psoriatic patients with metabolic syndrome had a higher mean age (p= 0.001), and higher mean BMI (p= 0.001) compared with the psoriatic patients without metabolic syndrome. The metabolic syndrome was not associated with the severity of psoriasis. Untreated patients with psoriasis have no significantly higher prevalence of the metabolic syndrome than healthy controls. Our data suggest that systemic antipsoriatic drugs may play an important role in the pathogenesis of the metabolic syndrome.

Cardiovascular and Metabolic Comorbidities in Patients with Plaque-Type Psoriasis Never Treated with Systemic Antipsoriatic Drugs: a Case-Control Study

Abstract Previous studies have shown a higher prevalence of cardiometabolic diseases among patients with psoriasis compared to non-psoriatics. However, little attention has been paid to the effects of systemic antipsoriatic drugs. The aim of this study was to investigate the association between psoriasis and these comorbidities, comparing untreated patients with psoriasis and population-based control non-psoriatic patients. A hospital-based case-control study included 122 patients with plaque-type psoriasis and 122 age- and gender-matched controls. Patients who ever received systemic antipsoriatic drugs were excluded. There were no significant differences between psoriatic patients and controls regarding the prevalence of hypertension (p=0.311), coronary heart disease (p=0.480), diabetes (p=0.641), myocardial infarction (p=0.71), stroke (2.4% vs. 2.4%, p=1.00) and metabolic syndrome (p=0.764). The prevalence of hypertriglyceridemia in patients with psoriasis and controls was 41.8% and 28.7%, respectively (OR 1.78, 95% CI 1.04-3.04, p=0.032). Furthermore, significant differences were observed in mean triglyceride levels (p=0.013). Smoking was significantly more often reported in psoriatic patients compared to controls. Patients with psoriasis also had a higher mean BMI (26.24, SD 4.42) compared with controls (24.73, SD 3.86), p=0.005. Psoriasis showed a statistically significant association with BMI obesity classification [χ2(4)=11.560, p=0.02]. The prevalence of cardiovascular and metabolic comorbidities was not significantly higher in patients with plaquetype psoriasis who were never treated with systemic antipsoriatic drugs, compared to population-based non-psoriatic controls. Our data suggest that systemic antipsoriatic drugs may play an important role in the development of these comorbidities. However, this study confirms that untreated psoriasis patients have three major modifiable increased cardiovascular risk factors, such as smoking, obesity and hypertriglyceridemia.

Can physician's self-estimates be used as a valid instrument to determine prescription frequencies of anti-psoriatic drugs? Comparison of the results of a cross-sectional study using self-estimates with actual prescription behavior documented in a cohort

Physicians' self-estimates of their own prescription behavior can be used as a tool to gather information on prescription frequencies. Self-estimates as a tool for health-care research on prescription frequencies need to be validated as a suitable method before it can be used widely. We performed a cross-sectional study inviting all dermatologists in Berlin and Brandenburg to give self-estimates of their own prescription behavior of anti-psoriatic drugs. The results were compared with the results from a consecutive 8-months cohort study with the same participants documenting their actual treatment choices during every visit of a psoriasis patient on a standardized documentation sheet. Differences between self-estimates and documented prescription patterns were analyzed with respect to systemic anti-psoriatic drugs and UV treatment. Fifty-one dermatologists participated. They documented an average of 91 patient visits each. Absolute differences between the self-estimates and the documented actual prescription behavior ranged from -2.5% to 1.4% for systemic treatments. For psoralen plus ultravioloet A (PUVA) treatment, the absolute difference was 3.3% and for ultraviolet B (UVB) 4.7%. Self-estimates were surprisingly exact. Self-estimates may be suggested as one tool to assess prescription frequencies, but further studies are needed to confirm their validity.

Association between traditional systemic antipsoriatic drugs and tuberculosis risk in patients with psoriasis with or without psoriatic arthritis: Results of a nationwide cohort study from Taiwan

Although the link between tuberculosis (TB) and biologics use is well established, the risk of TB among patients with psoriasis exposed to traditional systemic therapies remains elusive. The aim is to investigate the association between traditional systemic therapies and TB among patients with psoriasis. We conducted a retrospective cohort study on the risk of active TB among patients with psoriasis and psoriatic arthritis, using the National Health Insurance Research Database of Taiwan, 1996 through 2008. Standardized incidence ratios of TB were analyzed in comparison with age- and gender-matched general population. Logistic regression was used in a nested case-control analysis to estimate the odds ratios of TB related to exposure to traditional systemic agents during the year before TB development. Among the 81,266 patients in the psoriasis cohort, 497 new active TB cases were identified. The incidence rate of TB was 102 cases per 100,000 person-years among patients with psoriasis (standardized incidence ratio 1.22, 95% confidence interval 1.18-1.33). The risk of TB was higher in patients with severe disease (standardized incidence ratio 1.52, 95% confidence interval 1.46-1.74). To facilitate comparisons with the 497 active TB cases, a total of 1988 matched control subjects were selected for a nested case-control study. Patients taking systemic corticosteroids and nonsteroidal anti-inflammatory drugs were associated with higher incidence of TB, especially frequent users, after adjustment for multiple TB risk factors, drug exposures, hospital visits, and level of urbanization. Stratified analyses of current users and new users of these drugs revealed similar results. Finally, traditional systemic antipsoriatic treatment was not associated with TB on any of the analyses. The National Health Insurance Research Database did not contain information regarding severity of psoriasis, smoking status, alcohol use, diet, laboratory parameters, chest radiograph, or history of recent contact with an individual with TB. Misclassification of disease cannot be ruled out in a registry-based database. The accessibility of health care may be associated with the level of urbanization, which could confound the effect of drugs in multivariate analyses. Severe psoriasis may be associated with an elevated TB risk. Traditional systemic therapies do not seem to be strongly associated with TB occurrence.

Combination of adalimumab with traditional systemic antipsoriatic drugs – a report of 39 cases

Monotherapy with TNF-α inhibitors does not always produce a sufficient response in psoriasis patients. Combinations of TNF-α antagonists such as adalimumab with systemic antipsoriatic therapies such as methotrexate are not approved for use in psoriasis, and the published data are scarce. The charts of 39 psoriasis patients from 6 dermatology departments were reviewed retrospectively. All patients were given adalimumbab with another systemic antipsoriatic drug. Combination therapy with methotrexate was most common (n = 32), followed by acitretin (n = 4) and cyclosporine (n = 3). Combination therapy with methotrexate lasted 10.8 ± 11.2 months (mean), with cyclosporine for 6.8 ± 3.3 months, and with acitretin 12.9 ± 12.4 months. Combinations were effective in the majority of patients: 30/39 (76.9 %) had a good (n = 9) or excellent (n = 21) response. Two patients had a moderate response and 7 patients had a poor response and were switched to another treatment. Overall, safety was very good. Eighteen patients experienced 24 adverse events; none was severe and/or required hospitalization. Of these, 10/24 adverse events were infections, most often infections of the upper respiratory tract (n = 5), bronchitis (n = 2), and influenza (n = 1). Combinations of adalimumab with traditional systemic antipsoriatic treatments offer a promising method for managing severe or recalcitrant psoriasis. More data are needed to determine the long-term safety and efficacy of these combinations.

Association between systemic antipsoriatic drugs and cardiovascular risk in patients with psoriasis with or without psoriatic arthritis: A nationwide cohort study

Psoriasis is associated with ischemic heart disease (IHD). Results of prior studies have suggested that methotrexate (MTX) may improve vascular disease in patients with psoriasis and rheumatoid arthritis. The aim of this study was to assess the risk of new-onset IHDs in psoriasis patients, comparing those taking MTX with those taking other nonbiologic antipsoriatic drugs. In this retrospective cohort study, we utilized claims data from the National Health Insurance Research Database of Taiwan to identify 179,200 subjects who had received a diagnosis of psoriasis, with or without psoriatic arthritis, on at least 3 visits. The risk of hospitalization for new-onset IHD was compared between psoriasis patients taking MTX monotherapy (n = 6,578; MTX case cohort) and psoriasis patients taking other nonbiologic antipsoriatic drugs (n = 5,471; reference control cohort) between January 1996 and December 2008. Additional adjustments were made for cardiovascular risk factors, number of hospital visits, Charlson comorbidity score, and use of other antiinflammatory drugs. The incidence rates of IHD were 666 cases per 100,000 person-years in the MTX case cohort and 830 cases per 100,000 person-years in the reference control cohort (unadjusted P = 0.027). Increasing age, male sex, presence of hypertension, presence of diabetes, Charlson comorbidity score, and use of phototherapies were independent risk factors for hospitalization related to a new IHD in the study cohorts. However, the multivariate-adjusted hazard ratio for IHD-related hospitalizations among patients receiving MTX, in comparison with those receiving other nonbiologic antipsoriatic drugs, was 0.97 (95% confidence interval 0.79-1.19), after adjustment for age, sex, comorbidity score, number of hospital visits, and other antiinflammatory treatments for psoriasis. In patients with psoriasis with or without coexisting psoriatic arthritis, the adjusted risk of hospitalization for an IHD among individuals receiving MTX was comparable with that among individuals receiving other nonbiologic antipsoriatic drugs.

Increased risk of infectious disease requiring hospitalization among patients with psoriasis: A population-based cohort

Immunologic alterations caused by psoriasis and/or its therapies may affect the risk of serious infections. For patients with psoriasis, we explored the overall and therapy-related risk of contracting an infectious disease (ID) requiring hospitalization in a large population-based cohort. The incidence of ID was compared between patients with psoriasis and a randomly selected cohort (ratio 1:5) using hospital and pharmacy databases covering 2.5 million Dutch residents between 1997 and 2008. First and multiple IDs were defined and categorized into 20 groups based on primary International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnoses. Multivariate Cox regression and Poisson event-count models were used to test the risk difference of IDs between patients with psoriasis and reference cohort. A total of 25,742 patients with psoriasis and 128,710 reference subjects were followed up for approximately 6 years. The likelihood of IDs in patients with psoriasis was twice as high as the reference population (908 vs 438 events/100,000 person-years, crude hazard ratio 2.08, 95% confidence interval 1.96-2.22). In a multivariate model the hazard ratio decreased to 1.54 (95% confidence interval 1.44-1.65). This risk was highest for patients with more severe psoriasis (adjusted hazard ratio 1.81, 95% confidence interval 1.57-2.08), but was not associated with recent systemic antipsoriatic drug dispensing. Respiratory tract, abdominal, and skin infections occurred most frequently in patients with psoriasis. Multiple event analysis that counted the total number of infectious discharge diagnoses gave similar results. No data were available on lifestyle factors. The risk of severe infections was significantly higher for patients with psoriasis compared with control subjects and could not be explained by exposure to systemic antipsoriatic drugs.

Komorbiditäten bei Psoriasis vulgaris

Epidemiologic data document not only a higher prevalence of joint involvement among psoriasis patients than previously thought, but also an association with numerous other diseases, including depression, smoking, alcoholism, Crohn's disease, and metabolic syndrome. The resulting increased cardiovascular mortality is of particular clinical importance, and its pathogenetic link as a complication of the psoriatic inflammation is well recognized. Thus, we need to re-invent the management of psoriasis: Dermatologists are not only the sentinel regarding the early diagnosis of psoriatic arthritis, but also of metabolic complications such as dyslipidemia or diabetes. Moreover, they need to keep in mind interactions between (systemic) anti-psoriatic drugs and the co-medication of their patients as well as possible consequences of these co-medications on the course of psoriasis. To successfully accomplish this mission, a comprehensive management concept and ground-breaking research are urgently needed.

Psoriasis and hepatitis C treated with anti-TNF alpha therapy (etanercept)

The treatment of severe psoriasis in patients with concomitant hepatitis-C virus infection is quite difficult because several systemic anti-psoriatic drugs are contraindicated owing to their liver toxicity. Recent observations in the literature suggest that etanercept is an effective and safe therapy for this setting of patients. We present a 45-year-old man with extensive plaque psoriasis and concurrent hepatitis C, successfully treated with 12-month etanercept monotherapy. Regular controls of hepatic enzymes and viral load during the treatment disclosed no worsening of baseline values. This case confirms that etanercept may be a safe option for the therapy of patients with psoriasis and hepatitis-C virus infection.

The use of ciclosporin in psoriasis

Ciclosporin is a cyclic undecapeptide discovered in the 1970s to possess a potent inhibitory action on T lymphocytes. The subsequent discovery, in 1979, that it was remarkably effective in treatment of psoriasis transformed thinking about the nature of the disease, which subsequently became generally recognized as autoimmune in nature. Ciclosporin remains one of the most effective and rapidly acting treatments currently available for psoriasis. Virtually all the diverse manifestations of this disease can respond. The main side effects are nephrotoxicity and hypertension. There is considerable variation between individuals in susceptibility to these so careful monitoring is required. Ciclosporin should be used in single or intermittent short courses for all except the most severe cases as this is safer than continuous treatment. The rate of improvement depends very much on the dose, which ranges from 2 to 5.0 mg/kg/day. Ciclosporin can be combined with any topical treatment and a useful dose‐sparing effect can be achieved in this way if patients are compliant. In severe cases ciclosporin is often used in combination with other systemic antipsoriatic drugs in order to spare the dose of each agent and reduce toxicity. Concurrent or intercurrent use of ultraviolet therapy is discouraged due to the increased risk of non‐melanoma skin cancer. This article reviews the mode of action, pharmacokinetics, indications, contraindications, side effects, dosage regimens, pretreatment screening and monitoring, drug interactions, and use of treatment combinations with ciclosporin in the management of psoriasis.

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.