Topical Calcipotriol Research Articles

A Case of Segmental Vitiligo with Generalized Morphea Stabilized by Antimalarial Medication.

Dear Editor: A 10-year-old girl presented with a round, brown to whitish, atrophic plaque on the right side of her back, which she has had for 5 years. Histologic findings showed thick collagen bundles with lymphocytic infiltrations around the vessel in the dermo-subcutaneous tissue, which are consistent with morphea. Only topical calcipotriol was used due to the limited localization of the plaque and the young age of the patient. However, after 6 months, a new morphea lesion developed on the left side of the back and linear scleroderma occurred on the forehead. The patient was diagnosed with generalized mixed-type morphea, with two circumscribed morphea on the right and left sides of the back (Fig. 1A) and linear scleroderma on the forehead (Fig. 1B). Hypopigmented lesions were also present on her left leg and on the left side of the trunk (Fig. 1C). Based on Wood's light examination and clinical findings, the patient was diagnosed with segmental vitiligo (SV). Fig. 1 (A) Two circumscribed morphea on the right and left sides of the back. (B) Linear scleroderma on the left side of the forehead. (C) Vitiliginous lesions on the left side of the trunk. The vitiliginous lesions and linear scleroderma on the forehead showed progression despite the combination therapy using intermittent oral steroid, topical calcineurin inhibitor, and narrowband ultraviolet B phototherapy for 1 year. To block the progression of morphea, hydroxychloroquine sulfate (200 mg/day) was used. Skin lesions of morphea and vitiligo stabilized within 6 weeks. In addition, the vitiliginous lesions showed 70% repigmentation after 5 months from start of medication. Skin lesions of morphea also showed no more progression. The patient tolerated the 7-month treatment period with no side effects (Fig. 2). Fig. 2 Flow diagram during the follow-up period. NBUVB: narrowband ultraviolet B. Although the pathogenesis of vitiligo remains unknown, an immunological mechanism is strongly considered. However, SV is associated with a neurogenic mechanism. Furthermore, an immune-mediated mechanism known as the three-step theory has been reported to be involved in the pathogenesis of SV, according to a case report showing simultaneous occurrence of SV, alopecia areata, psoriasis, and halo nevus1. The association of SV with scleroderma has been rarely reported2. Bonifati et al.3 reported the case showing linear scleroderma on the left limb and homolateral SV on the trunk. Contrary to previous reports, our patient had generalized morphea lesions on the right and left sides of the back and linear scleroderma on the left side of the forehead, which was on the same side of the body where SV was located. Our case study suggested that hydroxychloroquine is effective not only in blocking the progression of scleroderma4 but also in treating vitiligo. Walsh et al.5 reported two systemic lupus erythematosus patients with exextensive widespread vitiligo-like depigmentations who showed rapid responses to hydroxychloroquine. Although we cannot exclude the possibility of coincidental development of SV and scleroderma, our case suggested that vitiligo and scleroderma that have the same autoimmune background can occur at the same time because they occurred during the same period and progressed in parallel for several years. In addition, this concomitant presence could support the theory that SV is associated with an autoimmune background. Moreover, our report suggested that an antimalarial drug could be used as a promising option for the treatment of vitiligo.

Topical calcipotriol/betamethasone dipropionate for psoriasis vulgaris: A systematic review.

Topical calcipotriol/betamethasone dipropionate ointment/gel has been commonly used for the treatment of psoriasis vulgaris. However, the efficacy of this combination needs to be consolidated. We aimed to assess the effects and safety profile of calcipotriol/betamethasone dipropionate for the treatment of psoriasis vulgaris, using evidence based approach. Randomized controlled trials on the treatment of psoriasis vulgaris with calcipotriol/betamethasone dipropionate were identified by searching PubMed, China National Knowledge Infrastructure and the Cochrane Library. The primary outcome measure was the Psoriasis Area and Severity Index (PASI) score. Ten randomized controlled trials involving 6590 participants were included. The methodologies of the studies were generally of moderate to high quality. These trials used topical calcipotriol/betamethasone dipropionate for 4 or 8 weeks, and were compared with topical calcipotriol or betamethasone. The results showed that calcipotriol/betamethasone dipropionate was more effective than controls. A four-week treatment with calcipotriol/betamethasone dipropionate did not show any significant difference between the once-daily or twice-daily regimen. The adverse events of calcipotriol/betamethasone dipropionate were tolerable and acceptable. The reports included in this review are heterogenous and have limitations. Topical application of calcipotriol/betamethasone dipropionate once daily is an efficacious treatment for psoriasis vulgaris and is associated with few side effects.

Comparative Efficacy of Topical Calcipotriol (0.005%) Versus Topical Corticosteroid (Betamethasone 0.1%) in Treating Plaque Type Psoriasis

A clinical trial was carried out to compare the efficacy of topical calcipotriol (0.005%) and topical corticosteroid (betamethasone 0.1%) in the treatment of plaque type psoriasis. The study was conducted from January 2012 to August 2012 and patients of plaque type psoriasis attending outpatient department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University, Dhaka were the study population. Patients were divided into two groups, group A was treated with topical calcipotriol (0.005%) ointment and group B with topical corticosteroid (betamethasone 0.1%) ointment. The mean baseline PASI score was 6.7 ±4.5 and after 8 weeks, the mean PASI score was 2.0 ±1.4 for group A and mean baseline PASI score was 5.5 ±4.2 and after 8 weeks, the mean PASI score was 2.5 ±1.4 for group B. There was statistically significant reduction in PASI score from base line after 8 weeks of treatment in both treatment groups (p < 0.001). After 8th week of treatment moderate response was 11(73.3%) in group A and 9(60%) in group B. Very good response was 4 (26.7%) in group B and 2 (13.3%) in group A and minimal response of treatment occurs equally 2 (13.3%) in group A and group B. In the light of the findings of the study we conclude that each of the treatment of calcipotriol(0.005%) and betamethasone (0.1%) is individually effective. Further multicenter, randomized, double-blind study should be conducted with large sample size.Medicine Today 2014 Vol.26(2): 88-94

The mastocyte: the off switch of UV itch.

The mastocyte: the off switch of UV itch.

Imatinib-induced exacerbation of psoriasis in a patient with recurrent dermatofibrosarcoma protuberans: A case report and review of the literature

Abstract Imatinib, a tyrosine kinase inhibitor, is the current preferred agent for the treatment of unresectable or metastatic dermatofibrosarcoma protuberans (DFSP). We present the first case report with exacerbated psoriasis during imatinib treatment for recurrent DFSP. The condition of a 63-year-old man with a history of psoriasis vulgaris for 17 years was controlled well by topical calcipotriol. He suffered from a recurrent DFSP, and the molecular pathology analysis showed OL1A1–PDGFB fusion transcript. Imatinib (400 mg daily) was commenced after surgical excision, and 4 weeks later he developed generalized psoriasis that was poorly controlled by regular treatment. After discontinuation of imatinib, combined with systemic antihistamine and topical corticosteroid, the lesions improved in 8 weeks. We further reviewed the literature to characterize the imatinib-induced psoriasis.

Efficacy of topical Calcipotriol versus combination of topical Calcipotriol plus Betamethasone in the treatment of plaque type psoriasis

Introduction: The effectiveness of various topical agents for the treatment of plaque psoriasis is limited and the results are somewhat not satisfactory to some extent. Topical Calcipotriol can be used either monotherapy or combination therapy with betamethasone. This topical agent has “corticosteroid-sparing” benefit and reduction of side effects, duration of treatment and also relapse rates when used as combination therapy for the treatment of psoriasis. Objectives: The present study was conducted to compare the clinical efficacy between the topical Calcipotriol and combined formulation of topical Calcipotriol plus Betamethasone in the treatment of plaque type psoriasis. Materials and Methods: A clinical trial was carried out from January 2011 to Jan 2014 in outpatient department of Dermatology and Venereology, combined military hospital- Dhaka and Jessore Cantonment and Bangabandhu sheikh Mujib Medical University, Dhaka. Patients of plaque type psoriasis were the study population. Consequitive type of non-probability sampling method was followed in this study. Patients were divided into two groups.Group A was treated with topical Calcipotriol (0.005%) ointment and group B with combination of topical Calcipotriol plus Betamethasone ointment. Results: The mean percentage of Psoriasis Area and Severity Index (PASI) reduction after 4th week of treatment was 39.4 and 35.4 in group A and group B (p value >0.05) and after 8th week of 74 JAFMC Bangladesh. Vol 10, No 1 (June) 2014 therapy was 59.6 in-group A and 60.7 in-group B respectively. The mean baseline PASI score was 6.7±4.5 and after 8th week it was 2.0 ±1.4 for group A and mean baseline PASI score was 5.5 ±4.2 and after 8th week it was 2.5±1.4 for group B. There was statistically significant reduction in PASI score from base line after 8th week of treatment in both treatment groups (p < 0.001). After 8th week of treatment moderate response was 22(73.3%) in group A and 18(60%) in group B. Very good response was 4 (13.3%) in group A and 8 (26.7%) in group B and minimal response of treatment occurs equally 4 (13.3%) in group A and group B. Conclusion: In the light of the findings of this study, topical Calcipotriol(0.005%) alone or combination with Betamethasone is individually effective for the treatment of plaque psoriasis but combination therapy is more effective than monotherapy. Therefore it may be recommended that monotherapy can be replaced by combination therapy in treating plaque psoriasis. DOI: http://dx.doi.org/10.3329/jafmc.v10i1.22929 Journal of Armed Forces Medical College Bangladesh Vol.10(1) 2014

Narrow band UVB monotherapy versus topical calcipotriol ointment combined with narrow band UVB phototherapy for treatment of psoriasis vulgaris

Introduction: Calcipotriol and narrow-band ultraviolet B (NBUVB) phototherapy are widely used to effectively treat psoriasis. To reduce the cumulative NBUVB doses and to enhance clearance of psoriatic plaques, combination therapies have been established. Objectives: To compare the clinical efficacy of NBUVB alone and in combination with topical calcipotriol ointment in psoriasis. Patients and Methods: Fifty five patients with psoriasis vulgaris were included in the study. Patients were randomized into two treatment groups. Group I consisted of 30 patients who received NBUVB phototherapy as monotherapy and group II consisted of 25 patients who were treated with topical calcipotriol ointment combined with NBUVB. The treatment was continued till the patients achieved PASI-75. Results: Twenty patients, in each group, completed the study. At baseline, the mean PASI scores were 15±4 and 16.4±3 in group I and group II respectively, and at the end of treatment, the mean PASI scores were 6.5±3 in group I and 3.4±2 in group II (P=0.000). The total cumulative NBUVB dose and the number of sessions were significantly higher in group I compare to group II. Conclusion: Topical calcipotriol combined with NBUVB reduces the cumulative dose of NBUVB and improves the response of psoriasis vulgaris to phototherapy.

Effects of Rusanda Spa balneotherapy combined with calcipotriol on plaque psoriasis.

Treatment of psoriasis is very complex and there are no still universal, nor unique treatment modalities. Apart from conventional treatment, which includes topical calcipotriol (vitamin D3 analogue), balneotherapy is drawing increased attention worldwide. Being part of climatotherapy, balneotherapy is defined as the use of natural environmental factors in the treatment of health conditions, whereas in the treatment of psoriasis it means the use of mineral baths and peloids. The aim of this study was to examine the therapeutic efficacy of mineral waters and peloids of the Rusanda Spa on plaque psoriasis in patients also treated with calcipotriol. The study included 60 patients divided into two groups. The first group included patients treated with mineral waters, peloids and calcipotriol in the Rusanda Spa, while the second one included those treated only with calcipotriol. The study took 21 days, and each patient was followed up for at least one month after ending the treatment. The treatment efficacy was measured by psoriasis area severity index (PASI) scores on the days 0, 7, 14 and 21 during the treatment and 30 after the end of the therapy. After a 3-week treatment in the Rusanda Spa, the first group showed a decrease in PASI score by 59.45%, whereas in the group of outpatients treated by calcipotriol it was 39.34%. On the day 30 following the treatment, the first group presented with the PASI score reduction of 58.44%, and the second group of 34.78%. The therapeutic efficacy of mineral waters and peloids combined with calcipotriol showed to be significantly higher in regard to monotherapy with calcipotriol (p < 0.05). In regard to clinical symptoms, the best results were obtained in the reduction of desquamation (p < 0.001). The results of our study show that in the treatment of plaque-type psoriasis, topical calcipotriol combined with Spa Rusanda balineotherapy is more effective than topical calcipotriol alone. Randomized controlled trials are needed to confirm the effects of balneotherapy as monotherapy in treatment of this type of psoriasis.

Oral granulated Chinese herbal medicine (YXBCM01) plus topical calcipotriol for psoriasis vulgaris: study protocol for a double-blind, randomized placebo controlled trial.

BackgroundProbably related to immune dysfunction, psoriasis vulgaris is a chronic, painful, disfiguring and disabling dermatological disease, carrying an increased risk of serious comorbidities. Current conventional therapies can be costly, show risks of side effects and have limited efficacy, with relapse common on treatment cessation. Chinese herbal medicine is effective in treating psoriasis vulgaris. However, any benefit of adding Chinese herbal medicine to conventional treatments when treating psoriasis vulgaris is yet to be determined.Methods/designThis is a pilot randomized, placebo controlled, double-blinded trial. The pilot is primarily to determine the feasibility of undertaking a full size randomized trial. Thirty participants with psoriasis vulgaris and Psoriasis Area Severity Index (PASI) scores ≥7 and ≤12 will be included. Participants will be randomized (in a 1:1 ratio) to receive oral granulated Chinese herbal medicine YXBCM01 plus topical calcipotriol 0.005% or oral YXBCM01 placebo plus topical calcipotriol 0.005% treatment for 12 weeks, with a 12-week follow-up phase. The Chinese herbal medicine or placebo will be administered orally as dissolvable granules. The primary outcome measure will be PASI change (%) from baseline to the end of treatment phase. Secondary outcomes will include safety, key psoriasis-related cytokine changes (for example, IL12, IL17 and IL 23) during the entire trial and symptom relapse rates at the end of the follow-up phase.DiscussionThe study will evaluate the feasibility of a randomized controlled trial investigating combined conventional and Chinese herbal medicine therapy for psoriasis vulgaris. The ingredients of YXBCM01 were selected based on literature, the expert opinion on herbal medicine and pre-clinical evidence, for instance Chinese herbal medicine possesses anti-inflammatory or antiproliferative properties.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12614000493640.

Oral Chinese herbal medicine combined with pharmacotherapy for psoriasis vulgaris: a systematic review.

Clinically, oral Chinese herbal medicine (CHM) is widely used in the treatment of psoriasis. This review evaluates the effects of oral CHM in combination with pharmacotherapy for psoriasis vulgaris. The Cochrane Library, PubMed, Embase, CINAHL, CNKI, and CQVIP were searched from their inceptions to November 2012. Randomized controlled trials (RCTs) investigating CHM plus pharmacotherapy compared to pharmacotherapy were included. Data were analyzed using Review Manager 5.1.0. Seventeen RCTs were included, conducted in China, and employed a diversity of both herbal medicines and pharmacotherapies. When the meta-analyses were restricted to studies that used a well-known pharmacotherapy as the comparator with 60% or greater clinical improvement in psoriasis as the outcome, five studies used oral acitretin, one used topical calcipotriol, and one used topical clobetasol propionate as control interventions. At the end of treatment, there was a benefit for the pooled result of the five studies that compared CHM plus acitretin with acitretin alone and no serious adverse events were reported. However, none of these studies was blind, so there is considerable risk of bias in this result. In addition, there was inadequate reporting of longer-term results, so it remains unclear whether the reported effect could be maintained or whether the prolonged use of the CHM in conjunction with acitretin would be safe. The main plants used in these studies, Rehmannia glutinosa root, Salvia miltiorrhiza root, and Lithospermum erythrorhizon root, have shown anti-inflammatory and/or antiproliferative effects in experimental studies. These actions may at least partially explain the observed results.

Improve efficacy of topical ALA-PDT by calcipotriol through up-regulation of coproporphyrinogen oxidase

Topical 5-aminolevulinic acid-mediated photodynamic therapy (topical ALA-PDT) is effective for treating oral precancerous lesions. The aim of this in vivo and in vitro study was to examine whether the efficacy of topical ALA-PDT could be further improved by calcipotriol (CAL). Precancerous lesions in the buccal pouch of hamsters were induced by dimethylbenz(a)anthracene (DMBA). Lesions were treated with multiple topical ALA-PDT with or without CAL pretreatment. ALA-induced protoporphyrine IX (PpIX) was monitored by in situ fluorescence measurement. The effect of CAL on heme-related enzymes (CPOX, PPOX, and FECH) were examined in an in vitro model using human squamous cell carcinoma (SCC) cells (SCC4, SAS) using Western blots. Fluorescence spectroscopy revealed that PpIX reached its peak level in precancerous epithelial cells of buccal pouch at 2.5 or 3.5h without or with CAL pretreatment, respectively. Both treatment regimens showed similar response rates, but the complete response was achieved after 5 times of ALA-PDT and 3 times of CAL-ALA-PDT (p<0.001). Pretreatment of SCC cells with 10(-8) or 10(-7)M CAL could result in a significant cell death (p<0.05) and an elevation of CPOX protein level. Topical CAL can improve the efficacy of ALA-PDT in treating precancerous lesions, likely through the increase in CPOX level and in PpIX production.

Genital Lichen Sclerosus – Has Th ere Been any Progress in Treatment?

Abstract Lichen sclerosus (LS) is a chronic inflammatory dermatosis localized mainly in the anogenital region, accompanied by itching, atrophy and sclerosis. Progressive destructive scarring in genital lichen sclerosus (GLS) may result in burying of the clitoris in females and phimosis in males. Affected persons have an increased risk of genital cancers. It is often unrecognized in everyday clinical practice due to undiagnosed squamous cell carcinoma at the site of lesions. Remissions are rare and the estimated remission rate is only 16%. GLS is a lifelong, incurable condition, but signifi cant improvement can be achieved. Numerous therapeutic modalities have been used in GLS; unfortunately, the number of controlled studies is small and the results are mostly related to the management of symptoms, not the progression of the disease and destructive scarring. A systemic meta analysis of seven randomized controlled trials on local therapy of GLS was performed. It included a total of 249 patients treated with six topical agents: clobetasol propionate, mometasone furoate, testosterone, dihydrotestosterone, progesterone and pimecrolimus. Topical corticosteroids, clobetasol propionate 0.05% (highly potent) and mometasone furoate 0.05% (potent), showed to be significantly more efficient compared to placebo. Pimecrolimus 1% cream and clobetasol propionate 0.05% showed similar efficacy. Both agents have proven effective in the treatment of GLS: there was no statistically significant difference in relieving symptoms of pruritus and burning/pain. Tacrolimus 0.1% ointment also proved to be effective in the treatment of GLS. Topical androgens and progesterone did not show significant efficacy. Topical tretinoin and calcipotriol have been used with limited success, but they may induce irritation, so they are rarely used in the treatment of GLS. Other therapeutic options for GLS include ultraviolet A1 (UVA-1) phototherapy, methotrexate, retinoids, cyclosporine, stanozolol, hydroxychloroquine, calcitriol, laser and photodynamic therapy, but the number of patients is small to allow for conclusive assessment. Surgery is not a standard therapeutic option for GLS. In conclusion, treatment of GLS should be carried out in two phases: introduction of remission and maintenance of remission; topical therapy should include highly potent corticosteroids once daily during three months, followed by twice per week, or twice daily during 4 to 6 weeks, and then twice per week. There are different opinions regarding maintenance therapy: application of super potent or potent topical corticosteroids; these patients need long-term, several-year follow-up, although there is no agreement what parameters should be assessed; treatment efficacy is often reduced to monitoring GLS symptoms.

The effect of topical calcipotriol or zinc on tuberculin skin tests in hospitalised South African children

The tuberculin skin test (TST) is used to help diagnose tuberculosis (TB) in acutely ill hospitalised children. OBJECTIVE To investigate the potential augmentative effect of topical calcipotriol (a vitamin D analogue) or zinc on TST induration. Three TSTs were performed among 64 hospitalised children; each site was covered with topical aqueous cream (control), calcipotriol or zinc and assessed 24 and 48 h later by investigators blinded to all topical applications. TSTs were reactive in 15 (23.4%) children, of whom 13 (20.3%) were TST-positive. Topical calcipotriol and zinc induced TST positivity in two children with reactive but negative control TSTs. These treatments, however, did not significantly increase TST positivity rates. In children with reactive TSTs, the median 48 h induration diameter was not significantly different between the control, calcipotriol- or zinc-treated groups, which were respectively 12.0 (25%-75% IQR 5.0 - 18.0), 14.0 (25%-75% IQR 10.0 - 15.0) and 12.0 (25%-75% IQR 8.0 - 15.0) mm. Topical treatments did not induce TST reactivity or TST positivity in children with culture-confirmed TB disease (n = 4), human immunodeficiency virus infection (n= 18) or kwashiorkor (n = 9). Topical calcipotriol or zinc does not induce TST reactivity or significantly increase TST positivity rates in acutely ill hospitalised children. However, further studies are required to assess the effects of topical treatments on TST positivity in severely malnourished children.

A case of psoriasis exacerbated by radioactive iodine therapy.

Dear Editor: Psoriasis is a chronic inflammatory skin disease that is characterized by erythematous, sharply demarcated papules and plaques covered by scales. Although the exact causes of psoriasis still remains obscure, it is known that genetic, immunological, and environmental factors contribute to its etiopathogenesis. Several factors such as trauma, stress, infections, and medications may exacerbate psoriasis. The most common medications known to trigger or worsen existing psoriasis include lithium, gold salts, beta blockers, and antimalarials. Exacerbation of psoriasis due to medications such as adrenergic antagonists, interferon, gemfibrozil, iodine, digoxin, and chlonidine has also been observed1. Radioactive iodine (RAI) therapy has been used for the remnant ablation and adjuvant therapy of thyroid cancer. The mechanism of RAI treatment is as follows: the thyroid gland needs iodine and absorbs it from the bloodstream, and then radiation destroys both cancerous and normal thyroid cells. Herein, we report the first case of psoriasis exacerbated by RAI therapy. A 32-year-old Korean woman presented with a 5-day history of erythroderma with papules and pustules on the whole body. On general inspection, generalized, scaly erythroderma with papules and pustules was observed (Fig. 1). She had a history of psoriasis for about 20 years and had undergone systemic narrow band ultraviolet (UV)-B phototherapy. Fig. 1 Generalized, scaly erythroderma with papules and pustules was observed on the arm (A) and abdomen (B) 5 days after radioactive iodine therapy. She received a diagnosis of papillary thyroid cancer and underwent total thyroidectomy 14 months previously. She was scheduled to have RAI therapy for thyroid cancer and was treated with phototherapy for psoriasis for up to 2 days before RAI therapy. Since then, she had applied topical steroid and calcipotriol ointment for the treatment of psoriasis. Five days after RAI therapy, erythroderma with papules and pustules developed over her whole body. Thus, this case was diagnosed as psoriasis exacerbated by RAI therapy. She applied topical desonide lotion and calcipotriol cream for 3 weeks, and clinical improvement was observed. She restarted to undergo systemic narrow band UV-B phototherapy for the treatment of psoriasis. Shelley2 reported two cases of generalized pustular psoriasis induced by potassium iodide. Kaufman3 observed that iodine/iodides specifically activate the enzyme dihydrofolic reductase. Methotrexate and aminopterin, as folic acid analogues, bind this enzyme, which blocks the metabolic steps in the synthesis of deoxyribronucleic acid and also blocks cell division4,5. Thus, activation of dihydrofolic reductase is associated with aggravation of the disease and inactivation associated with remission. This suggests that dihydrofolic reductase plays an important role in the pathogenesis of pustular psoriasis. We suspected that the mechanism in this case was related to the activation of dihydrofolic reductase through RAI. Further study about the folic acid pathway in psoriasis and the connection between RAI and psoriasis may be necessary.

Grover's Disease in a Liver Transplant Patient

Dear Editor: Grover's disease (GD) is a dermatosis of unknown aetiology that mostly affects men over 40 years-of-age. It is visually characterized by erythematous excoriated papules, which are usually located on the trunk, and is histologically characterized by acantholysis and dyskeratosis. GD has been reported in patients with chronic renal failure, malignancies, and in those with renal and bone marrow transplants1. A 56-year-old man complained of pruritic skin eruptions on his back and on both of his shins, which lasted for 3 months (Fig. 1). He had received a liver transplant 5 months previously for alcoholic liver cirrhosis. He had been taking mycophenolatemofetil, tacrolimus, and methylprednisolone for immunosuppression. Fig. 1 Brownish hyperkeratosis papules on the back (A) and both shins (B). His skin lesions comprised numerous brownish papules, about 2~5 mm in size, which were predominantly located on the backand on both shins. The patient showed no other abnormalities of the skin appendages or mucosa. There was no family history of skin disease. A biopsy of a brownish papule on the back showed epidermal hyperplasia with parakeratotic hyperkeratosis (Fig. 2). The epidermis showed suprabasalacantholysis and dyskeratotic keratinocytes. Corps ronds and grains were also evident along with a slight perivascular lymphohistiocytic infiltration of the dermis. The clinical and histological evidence was compatible with a diagnosis of GD, Darier's disease or Hailey-Hailey disease. The late onset, and the lack of family history and other characteristics consistent with Darier's disease, led to a final diagnosis of GD. The patient was treated with topical calcipotriol, although no clinical improvement was observed. Fig. 2 Histopathology of popular lesions (H&E). (A) Multifocal area of suprabasalclefting and acantholysis (×40). (B) Suprabasalclefting with corps ronds and grain (×200). The aetiology of GD is unknown. This disease is clinically and histologically indistinguishable from Darier's disease and Hailey-Hailey disease, although no mutations in the SERCA2 or SPCA1 genes have been detected in GD2. GD is frequently associated with exposure to heat and sunlight, sweating, and fever. Drugs, ionizing radiation, infection (Malassezia furfur or Demodexfolliculorum) and severe dermatosis (atopic dermatitis, allergic contact dermatitis, and asteatotic eczema) are also associated with GD3. GD has been reported in patients infected with human immunodeficiency virus, and in those with renal failure, haematologic malignancies, and solid carcinomas1. Also, the onset of GD after bone marrow transplantation (eight cases)4,5 and kidney transplantation (one case)1 has been described. To our knowledge, this is the first report of GD developing in a patient after liver transplantation followed by immunosuppressive treatment. Although it is unclear whether the aetiological mechanism underlying GD is immunologic, the immunosuppression may act as a trigger. Our case suggests that GD should be considered as a differential diagnosis in patients presenting with skin eruptions after liver transplantation with immunosuppression. The onset of GD after liver transplantation suggests an immunological mechanism. Further studies will be helpful to identify the relationship between GD and immunological mechanism.

Efficacy of adding topical simvastatin to topical calcipotriol on improvement of cutaneous plaque psoriasis

Background:Psoriasis is a common dermatologic disorder, with fluctuating response to treatment. Considering the proven immunomodulatory effects of oral simvastatin in psoriasis, this trial study was enrolled to determine whether the topical form has also antipsoriatic effects. Vitamin D analogs known to be effective and are considered the first line of therapy in mild to moderate cases. In this study, the efficacy of topical calcipotriol 0.005% ointment (as a standard method of treatment for psoriasis) versus combination of calcipotriol plus topical simvastatin is compared in the treatment of psoriasis.Materials and Methods:A total of 80 subjects with symmetric psoriasis who had body surface involvement up to 20% were divided randomly into 2 groups. Group A were treated with calcipotriol 0.005% ointment twice daily and Group B with calcipotriol 0.005% ointment twice daily and simvastatin 3% ointment twice daily for 12 weeks. The results were evaluated by a Blind Dermatologist using psoriasis area severity index (PASI) score at baseline, 4th, 8th and 12th week of treatment. In a similar way, a subjective assessment performed by patients based on photo-evaluation at the end of the study.Results:Despite a continuous reduction in PASI score in both groups, according to both physician (P = 0.603) and patient (P = 0.243) assessment topical simvastatin was not statistically more effective than conventional treatment of psoriasis at the end of the study.Conclusion:This study indicates that topical simvastatin is not associated with significant impacts in the treatment of psoriasis as compared to oral form. This study indicates that psoriasis is a systemic disorder with variable skin manifestations.

Circumscribed plantar hypokeratosis responding to topical calcipotriol

Circumscribed palmar or plantar hypokeratosis defines a benign condition clinically presented as a well-defined depressed area on the skin. It is characterized by a peculiar histopathological picture with the abrupt thinning of the horny layer of the epidermis. We present a case of a 17-year-old man, who presented with a one-year history of an occasionally painful lesion on his right sole. The diagnosis of circumscribed plantar hypokeratosis was confirmed by histopathology. The lesion was successfully treated with calcipotriol ointment. Circumscribed palmar or plantar hypokeratosis is a benign condition that typically affects the hands. Different therapeutic approaches have been unsuccessful. In our patient the lesion was at a less frequent plantar location and the lesion responded to topical calcipotriol.

A comparison of the effects of topical treatment of calcipotriol, camptothecin, clobetasol and tazarotene on an imiquimod-induced psoriasis-like mouse model

The interleukin-23/interleukin 17A (IL-23/IL-17A) cytokine axis plays a critical role in the pathogenesis of psoriasis. In this study, we report the effects of topical calcipotriol, camptothecin, clobetasol and tazarotene on the treatment of imiquimod (IMQ)-induced psoriasis-like inflammation, the development of which is dependent on the IL-23/IL-17A axis. IMQ-induced epidermal hyperplasia and inflammation in the BALB/c mouse ear were significantly inhibited following clobetasol treatment but not calcipotriol, camptothecin or tazarotene treatments. Real-time polymerase chain reaction showed that the mRNA levels of IL-17A, IL-17F, IL-22, IL-1β, IL-6 and TNF-α in ear skin were significantly decreased by clobetasol. In addition, we observed that calcipotriol, camptothecin and tazarotene failed to show any inhibitory effects on the IL-23/IL-17A/IL-22 axis. We also found that clobetasol treatment inhibited the proliferation of γδ T cells and C-C chemokine receptor type 6 (CCR6) expression induced by IMQ. Calcipotriol, camptothecin and tazarotene not only failed to inhibit this proliferation but also enhanced retinoic acid-related orphan receptor γ (RORγ) expression in IMQ-induced psoriasis-like inflammation. In conclusion, we suggest that clobetasol induces the relief of IMQ-induced psoriasis-like inflammation in a mouse model but that calcipotriol, camptothecin and tazarotene cannot. Therefore, we suggest that more in-depth studies on pharmacological effects of tazarotene, camptothecin and calcipotriol should be carried out.

Calcipotriol betamethasone ointment combined with narrow band-ultraviolet B in the treatment of plaque-type psoriasis: a randomized controlled study

Objective To assess the efficacy and safety of calcipotriol betamethasone ointment combined with narrow band-ultraviolet B (NB-UVB) for the treatment of plaque-type psoriasis.Methods A randomized,single-blind,parallel-controlled,multi-center clinical trial was conducted.Totally,108 patients with plaque-type psoriasis were randomly divided into the experiment group (treated with NB-UVB plus topical calcipotriol betamethasone ointment once daily in the evening) and control group (treated with NB-UVB only).The treatment lasted four weeks.The safety and efficacy were evaluated at the baseline,as well as two and four weeks after the beginning of treatment.Patients were scheduled for follow-up on week 1,2 and 4 after the end of treatment.Results The response rate was 15.09％ in the experiment group and 2.04％ in the control group after two-week treatment (P ＜ 0.01),77.36％ in the experiment group and 26.53％ in the control group at the end of treatment (P ＜ 0.01).Psoriasis area and severity index (PASI) score was similar between the two groups at the baseline,but significantly different from week 2 to week 8 after the beginning of treatment (all P ＜ 0.0I).Adverse reaction was observed in none of these patients,except for one patient in the control group who developed painful erythema in non-lesional sites of both legs.There was no significant difference in the incidence of adverse reactions between the two groups.Conclusion Calcipotriol betamethasone ointment combined with NB-UVB is a safe and effective treatment choice for plaque-type psoriasis with rapid onset of action.

A systematic review of clinical trials of treatments for the congenital ichthyoses, excluding ichthyosis vulgaris

The ichthyoses comprise a group of inherited disorders of keratinization. Because of the need for lifelong treatment, it is important that therapies are beneficial, safe, and well tolerated. We sought to review the evidence on existing treatments for the congenital ichthyoses, excluding ichthyosis vulgaris. We undertook a systematic review using the methodology of the Cochrane Collaboration. Articles published in MEDLINE, EMBASE, and CENTRAL and registered clinical trials were screened. Randomized controlled trials involving patients with the inherited ichthyoses, either syndromic or nonsyndromic but excluding ichthyosis vulgaris, were considered. Six trials met the inclusion criteria. Topical treatments including 5% urea, 20% propylene glycol alone or in combination with 5% lactic acid, calcipotriol ointment, and liarozole 5% cream showed therapeutic benefit. Oral liarozole, a retinoic acid metabolism blocking agent, showed no advantage over oral acitretin. Most studies were performed on a small sample of patients and lacked methodological and reporting quality. The small number of trials and the nearly constant positive results make publication bias likely. The absence of standardization of outcome measures precluded the comparison of studies. Topical treatments including emollients, calcipotriol ointment, and liarozole cream seem to have therapeutic benefit and a good safety profile, although the use of topical calcipotriol is limited by a maximum weekly dose of 100 g. The advantage of oral liarozole over acitretin is uncertain. Multicenter trials comparing oral and topical interventions and evaluation of long-term outcomes are needed.