Treatment Of Chronic Plaque Psoriasis Research Articles

Long-term treatment of chronic plaque psoriasis with biological drugs can control platelet activation: targeting the bridge between inflammation and atherothrombosis.

IntroductionPlatelet activation is elevated in moderate to severe psoriasis, and the reduction in platelet activation during short-term treatment has already been demonstrated. Soluble P-selectin is a well-established marker of platelet activation.AimTo show whether the long-term treatment of psoriasis with biological drugs can reduce elevated platelet activation.Material and methodsAn observational study of 27 patients with chronic plaque psoriasis, treated with infliximab, adalimumab, etanercept, or ustekinumab for up to 12 months was conducted. Psoriasis area and severity index (PASI), serum P-selectin and interleukin (IL)-6 were monitored throughout the treatment.ResultsThere was no significant correlation between PASI and platelet activation in our patients. After 3 months of treatment, a significant reduction in PASI and IL-6 was found, while P-selectin was not significantly reduced. When a cohort of patients who had shown elevated P-selectin prior to the treatment was evaluated, a significant reduction in P-selectin was observed in all 8 patients following 3 months; a reduction that was sustained after 6 and 12 months of therapy.ConclusionsWe conclude that PASI is not a good predictor of platelet activity in patients with PASI near to 10. Biological drugs reduce platelet activation in patients who have increased platelet activation prior to treatment, and this effect is stable during chronic therapy.

Cutaneous Lichen Planus Induced by Secukinumab

Lichen planus (LP) is a chronic mucocutaneous disease, characterised by an inflammatory immune response with sub-epithelial infiltration of T lymphocytes causing basal epithelial cell damage. Secukinumab is a monoclonal antibody that blocks IL-17A; which is the primary cytokine of Th17 cells involved in the aetiology of inflammatory skin diseases such as psoriasis. Secukinumab has been linked to induction of oral LP, but never directly to cutaneous LP. We report the first case of drug-induced cutaneous LP in the setting of secukinumab for treatment of chronic plaque psoriasis. A 56-year-old man with chronic plaque psoriasis presented with a 2-month history of violaceous and pruritic, thickened plaques on his bilateral lower limbs and buttocks in the setting of secukinumab use for psoriasis. Histological analysis showed a band-like lymphocyte inflammatory infiltrate just beneath the epithelium and was consistent with cutaneous LP. He was treated with topical betamethasone dipropionate cream with moderate effect. Initial laboratory tests including hepatitis and inflammatory screens were within normal limits. We hypothesise that this causal association may be due to a microbial trigger, activating a T-cell mediated immunologic response in CD8+ T-cells and dendritic cells, causing activation of type I interferons and an inflammatory skin response consistent with LP. Clinicians should monitor patients for mucosal and cutaneous LP when using secukinumab or other biologic modulators of IL-17 for extended periods with psoriasis.

Tofacitinib, an oral Janus kinase inhibitor, for the treatment of chronic plaque psoriasis: Long-term efficacy and safety results from 2 randomized phase-III studies and 1 open-label long-term extension study

Tofacitinib is an oral Janus kinase inhibitor being investigated for psoriasis. We sought to report longer-term tofacitinib efficacy and safety in patients with moderate to severe psoriasis. Data from 2 identical phase-III studies, Oral-treatment Psoriasis Trial Pivotal 1 and 2, were pooled with data from these patients in an ongoing open-label long-term extension study. Patients (n = 1861) were randomized 2:2:1 to tofacitinib 5 mg, 10 mg, or placebo twice daily (BID). At week 16, placebo patients were rerandomized to tofacitinib. Pivotal study participants could enroll into the long-term extension where they received tofacitinib at 10 mg BID for 3 months, after which dosing could be 5 or 10 mg BID. At week 28, the proportions of patients randomized to tofacitinib 5 and 10 mg BID achieving 75% or greater reduction in Psoriasis Area and Severity Index score from baseline were 55.6% and 68.8%, and achieving Physician Global Assessment of clear or almost clear were 54.7% and 65.9%. Efficacy was maintained in most patients through 24 months. Serious adverse events and discontinuations because of adverse events were reported in less than 11% of patients over 33 months of tofacitinib exposure. There was no dose comparison beyond week 52. Oral tofacitinib demonstrated sustained efficacy in patients with psoriasis through 2 years, with 10 mg BID providing greater efficacy than 5 mg BID. No unexpected safety findings were observed.

Use of Apremilast in Combination With Other Therapies for Treatment of Chronic Plaque Psoriasis: A Retrospective Study.

Apremilast is an oral phosphodiesterase 4 inhibitor that has been approved as monotherapy for the treatment of moderate to severe chronic plaque psoriasis. No data exist on the safety or efficacy of apremilast as a component of combination therapy with either phototherapy or conventional systemic or biological therapies. To evaluate the short term-efficacy and safety of apremilast in combination with at least one form of photo-, systemic, or biologic therapy in the treatment of chronic plaque psoriasis. A retrospective chart review was conducted for patients who received apremilast in addition to systemic, biologic, or phototherapy. The primary outcome was the proportion of patients achieving at least 75% improvement in Psoriasis Area and Severity Index score (PASI-75). A total of 81 patients with plaque psoriasis were treated with apremilast in combination with at least 1 other therapy (NB-UVB, methotrexate, acitretin, cyclosporin, etanercept, adalimumab, infliximab, or ustekinumab). Fourteen patients (17%) discontinued treatment before completion of 12 weeks of apremilast therapy. Sixty-seven patients continued on drug past 12 weeks. Of these patients, 81% achieved PASI-75 at week 12 after apremilast was added to an existing therapy. Nausea and/or diarrhea were reported in 25% of these patients, and weight loss was observed in 15%. Apremilast can be safely and effectively combined with phototherapy, systemic, and/or biological agents in patients with plaque psoriasis not responding adequately to these agents alone. Gastrointestinal side effects were manageable in the majority of patients.

Can We Repurpose FDA-Approved Alefacept to Diminish the HIV Reservoir?

Current anti-retroviral treatment (ART) for HIV is effective in maintaining HIV at undetectable levels. However, cessation of ART results in immediate and brisk rebound of viremia to high levels. This rebound is driven by an HIV reservoir mainly enriched in memory CD4+ T cells. In order to provide any form of functional HIV Cure, elimination of this viral reservoir has become the focus of current HIV cure strategies. Alefacept was initially developed for the treatment of chronic plaque psoriasis. Alefacept is a chimeric fusion protein consisting of the CD2-binding portion of human leukocyte function antigen-3 (LFA3) linked to the Fc region of human IgG1 (LFA3-Fc). Alefacept was designed to inhibit memory T cell activation that contributes to the chronic autoimmune disease psoriasis by blocking the CD2 coreceptor. However, it was found to deplete memory T cells that express high levels of CD2 via NK cell-mediated antibody dependent cell cytotoxicity (ADCC) in vivo. Phase II and phase III clinical trials of alefacept with psoriasis patients demonstrated promising results and an excellent safety profile. Subsequently, alefacept has been successfully repurposed for other memory T cell-mediated autoimmune diseases including skin diseases other than psoriasis, organ transplantation and type I diabetes (T1D). Herein, we review our specific strategy to repurpose the FDA approved biologic alefacept to decrease and hopefully someday eliminate the HIV reservoir, for which CD2hi memory CD4+ T cells are a significant contributor.

Anti-TNF agents for paediatric psoriasis.

Psoriasis is a chronic skin disease that may develop at any age. Estimates for the United States and Europe suggest that psoriasis accounts for 4% of skin diseases in children. In most cases, the condition is mild and can be treated with creams. However, a small percentage of children have moderate to severe disease that requires drugs, such as ciclosporin or methotrexate, and some will require injections with newer biological agents, such as anti-TNF (tumour necrosis factor) drugs. Anti-TNF drugs (among them etanercept, infliximab, and adalimumab) are designed to reduce inflammation in the body caused by tumour necrosis factor. Evidence for the safety and efficacy of these biological agents in paediatric psoriasis is lacking. To assess the efficacy and safety of anti-TNF agents for the treatment of paediatric psoriasis. We searched the following databases up to July 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 6), MEDLINE (from 1946), Embase (from 1974), and LILACS (from 1982). We also searched 13 trials registers and checked the reference lists of included studies and key review articles for further references to relevant randomised controlled trials (RCTs). We handsearched conference proceedings and attempted to contact trial authors and relevant pharmaceutical manufacturers. We searched the US Food and Drug Administration's and European Medicines Agency's adverse effects databases. All relevant RCTs that evaluated the efficacy and safety of anti-TNF agents for the treatment of chronic plaque psoriasis in individuals less than 18 years of age. Two review authors independently checked titles and abstracts and performed data extraction and 'Risk of bias' assessment of the included studies. One review author entered data into Review Manager (RevMan), and a second review author checked the data. We also attempted to obtain unclear data from the trial authors where possible.Our primary outcomes were investigator-assessed number of participants achieving a 75% improvement in Psoriasis Area and Severity Index-75 (PASI 75) compared to baseline, improvement in quality of life using an instrument such as Children's Dermatology Life Quality Index (CDLQI), and adverse effects. Our secondary outcomes included the proportion of participants achieving PASI 50 and the Physician's Global Assessment (PGA). We included one study with 211 participants (median age 13 years), in which etanercept (dosage ranged from 0.8 to 50 mg per kilogram of body weight) was compared to placebo. Follow-up was over a 48-week period.At week 12, 57% versus 11% who received etanercept or placebo, respectively, achieved the PASI 75 (risk ratio 4.95, 95% confidence interval (CI) 2.83 to 8.65; high-quality evidence). Absolute risk reduction and the number needed to treat to obtain a benefit with etanercept was 45% (95% CI 33.95 to 56.40) and 2 (95% CI 1.77 to 2.95), respectively.The percentage improvement from baseline of the CDLQI scores at week 12 was better in the etanercept group than the placebo group (52.3% versus 17.5%, respectively (P = 0.0001)). Analysis between the groups showed an effect size that was clinically important (mean difference 2.30, 95% CI 0.85 to 3.75; high-quality evidence). However, means, medians, and minimal important difference results and results of the Pediatric Quality of Life Inventory, Stein Impact on Family Scale, and Harter Self-Perception Profile for Children scores must be interpreted with caution, as they were not prespecified outcomes.Three serious adverse events were reported, but they were resolved without sequelae. Deaths or other events such as malignant tumours, opportunistic infections, tuberculosis, or demyelination were not reported in the included study.Also, 13% of participants in the placebo group and 53% in the etanercept group had a PGA of clear or almost clear (risk ratio 3.96, 95% CI 2.36 to 6.66; high-quality evidence) at week 12. This review found only one RCT evaluating the use of this type of biological therapy. Although the risk of publication bias was high, as we included only one industry-sponsored RCT, the risk of allocation, selection, performance, attrition, and selective reporting biases for all outcomes (except for CDLQI) was low, and no short-term serious adverse events were found.We can conclude, based on this single included study, that etanercept seems to be efficacious and safe (at least in the short term) for the treatment of paediatric psoriasis. However, as the GRADE approach refers not to individual studies but to a body of evidence, we shall wait for the results of the ongoing studies in a future update of this review. In addition, future studies should evaluate quality-of-life endpoints established a priori and standardise primary outcome measures such as PASI 75, and should include the PGA as a secondary endpoint. Also, collating and reporting adverse events uniformly is required to better evaluate safety.

Liposomal fusidic acid as a potential delivery system: a new paradigm in the treatment of chronic plaque psoriasis

Chronic plaque psoriasis is an inflammatory skin disease affecting 2–3% of the world population. With increasing understanding of the progress of disease and its causes, bacterial infection is reported to be one of the potential reasons. In this regard, fusidic acid (FA), a steroidal antibiotic, has been a drug of choice which could play an important role by virtue of its unique mechanism of action. Despite many topical formulations of FA in practice, drug-delivery issues like permeability in the prevailing infectious conditions and stability of the drug are yet the challenges not been covered so far from the formulation development perspective. For these issues, liposomes, on account of their carrier-specific properties, have been suggested as delivery tools to fulfill the expectations. In the present work, FA liposomes (FA-LP) were prepared and characterized for its varied traits such as size (420–740 nm), surface charge, morphology, percent skin permeation (>75%), and retention (1.620 ± 0.8 mg/cm2). Confocal laser scanning microscope (CLSM) images revealed appreciable cell-uptake of fluorescent dye-loaded liposomes. In stability, FA-LP proved to be stable with respect to drug leakage and vesicle size. In vivo studies using the mouse tail model, FA-LP, are found significantly better (p < 0.05) vis-à-vis conventional one with improved efficacy in and around the target site by the carrier-effect. Hence, the work suggests for the possibility of a better FA liposome-based formulation as a potential option in addressing the infectious challenges of psoriasis.

Five-year experience with infliximab: Follow up of the product familiarisation program.

This 5-year retrospective analysis is of 22 patients who participated in the product familiarisation program (PFP) at St Vincent's Hospital Melbourne, prior to the listing of infliximab on the Pharmaceutical Benefit Scheme. Criteria for inclusion were being an adult with chronic plaque psoriasis, having a psoriasis area and severity index (PASI) score of at least 15 with an inadequate response or intolerance to three of the following: phototherapy, acitretin, cyclosporin and methotrexate. Participants were infused with infliximab 5 mg/kg on the standard induction (weeks 0, 2 and 6) and maintenance (8-weekly) protocols. At each visit PASI and dermatology life quality index (DLQI) scores were recorded. Success was determined as the proportion of patients achieving at least a 75% improvement in the PASI score from baseline (PASI 75). At 60 months after commencement of therapy, 31% of patients remained on infliximab. Those who did retained PASI 75 with a DLQI of 0 or 1. Of those who ceased infliximab, nine did so due to loss of efficacy, three for personal reasons, two for serious adverse events and one was lost to follow up. Adverse events included non-melanoma skin cancers, infections and abnormal liver enzymes. Infliximab in the Australian context has proven to be a highly effective treatment of chronic plaque psoriasis, and patients who remained on the drug derived a high level of satisfaction, assessed both subjectively (DLQI) and objectively (PASI 75). The variable response indicates that psoriasis is a heterogeneous disease and investigation into potential patient selection for treatment in the future is warranted.

The impact of biologic therapy in chronic plaque psoriasis from a societal perspective: an analysis based on Italian actual clinical practice.

Psoriasis is one of the most common forms of chronic dermatitis, affecting 2-3% of the worldwide population. It has a serious effect on the way patients perceive themselves and others, thereby prejudicing their quality of life and giving rise to a significant deterioration in their psycho-physical well-being; it also poses greater difficulties for them in leading a normal social life, including their ability to conduct a normal working life. All the above-mentioned issues imply a cost for the society. This study proposes to evaluate the impact on societal costs for the treatment of chronic plaque psoriasis with biologics (etanercept, infliximab and adalimumab) in the Italian clinical practice. A prospective observational study has been conducted in 12 specialized centres of the Psocare network, located throughout Italy. Direct and indirect costs (as well as the health-related quality of life of patients with plaque psoriasis undergoing biologic treatments) have been estimated, while the societal impact has been determined using a cost-utility approach. Non-medical and indirect costs account for as much as 44.97% of the total cost prior to treatment and to 6.59% after treatment, with an overall 71.38% decrease. Adopting a societal perspective in the actual clinical practice of the Italian participating centres, the ICER of biologic therapies for treating plaque psoriasis amounted to €18634.40 per QALY gained--a value far from the €28656.30 obtained by adopting a third-party payer perspective. Our study confirms that chronic psoriasis subjects patients to a considerable burden, together with their families and caregivers, stressing how important it is to take the societal perspective into consideration during the appraisal process. Besides, using data derived from Italian actual practice, treatment with biologics shows a noteworthy benefit in social terms.

Combination therapy of methotrexate plus NBUVB phototherapy is more effective than methotrexate monotherapy in the treatment of chronic plaque psoriasis

Background: The efficacy of methotrexate (MTX) plus narrowband ultraviolet B (NBUVB) phototherapy in treatment of chronic plaque psoriasis has been rarely assessed. Objectives: The objective of this study is to compare the efficacy of MTX/NBUVB phototherapy versus MTX monotherapy in treatment of chronic plaque psoriasis. Methods: Forty patients with psoriasis were enrolled into the study and classified into group A receiving oral MTX and group B receiving oral MTX plus NBUVB. Onset of improvement was ≤70% of baseline PASI. End point clearance was 90 % reduction in PASI or up to 6 months. Side effects were reported. Follow up for 12 weeks for assessment of relapse was done. Results: Of 40 patients, 35 completed the study. A higher clearance rate was achieved in patients of group B versus group A (100% versus 83%). A significant difference was reported regarding the onset of improvement and the duration required for clearance (p < 0.001) in favor of the MTX/NBUVB group. Patients in group B had a highly significant lower cumulative dose of MTX than the monotherapy group (p < 0.05). No significant difference as regard side effects and relapse was reported. Conclusion: MTX remains the mainstay in the treatment of psoriasis in developing countries and its combination with NBUVB offers a cheap and a beneficial therapeutic option.

Systemic pharmacological treatments for chronic plaque psoriasis

Systemic pharmacological treatments for chronic plaque psoriasis

Network Meta-analysis of Treatments for Chronic Plaque Psoriasis in Canada.

Psoriasis affects approximately 500,000 Canadians. Eight treatments are currently licensed for chronic plaque psoriasis in Canada. To compare the efficacy of systemic treatments for chronic plaque psoriasis for the outcome > 75% reduction in the Psoriasis Area and Severity Index (PASI) using network meta-analysis. PubMed and clinicaltrials.gov databases were searched up until October 15, 2013, for phase III clinical trials. A consistency model based on a random-effects bayesian statistical framework was used to compare the rates of > 75% PASI reduction across trials. Twenty-one studies were included in the network analysis. Infliximab had significantly greater odds of producing > 75% reduction in the PASI compared to all treatments. All treatments conferred greater odds of > 75% PASI reduction compared to placebo. Although infliximab had the highest efficacy relative to other systemic treatments for psoriasis, adverse effects, cost, and patient preferences should also be considered when deciding on treatment.

Tonsillectomy and Antistreptococcal Interventions for Psoriasis: A Review

Psoriasis is a chronic skin condition that has been shown to have both genetic and environmental features. Streptococcal infection has been associated with the onset of psoriasis. The palatine tonsils represent an environment within the body that is particularly susceptible to infection and is ideal for antigen sampling. It is considered that psoriasis may be induced due to a cross-reactive T-cell response involving streptococcal M proteins and keratin containing homologous peptides. Antibiotics and tonsillectomy have been used for the treatment of chronic plaque psoriasis and guttate psoriasis. More recently, the first randomized, controlled clinical trial of tonsillectomy was performed. Here, we review the accumulating evidence pertaining to antistreptococcal interventions and tonsillectomy, and further consider their efficacy as treatment options.

Ponesimod—a future oral therapy for psoriasis?

Increased understanding of the role of sphingosine-1-phosphate (S1P) in modulating the circulation of T lymphocytes has led to development of a new class of targeted therapies for psoriasis.1 In The Lancet, Andrea Vaclavkova and colleagues2 report on a phase 2 study of ponesimod, the first oral selective modulator of the S1P receptor 1 (S1PR1), for the treatment of chronic plaque psoriasis. S1P is a lysophospholipid whose activity is mediated through five G-protein-coupled S1P receptors, and ponesimod is a selective S1PR1 antagonist that depletes surface S1PR1 and prevents T-lymphocyte egress from secondary lymphoid tissues into the circulation.

Methotrexate toxicity during treatment of chronic plaque psoriasis: a case report and review of the literature.

Methotrexate continues to be one of the most widely used systemic immunosuppressive agents in dermatology. In addition to the important, well-characterized adverse effects such as hepatotoxicity and myelosuppression, methotrexate may induce a number of rare cutaneous adverse events including methotrexate-induced ulceration. We present a case of methotrexate-induced cutaneous ulceration in a patient with chronic plaque psoriasis occurring during long-standing methotrexate therapy. Withdrawal of the drug and appropriate skin care led to rapid healing of the ulceration and the agent was later safely reintroduced for the ongoing management of the patient’s chronic plaque psoriasis. Review of the literature demonstrates cases of this important rare adverse event, primarily occurring in patients with chronic plaque psoriasis, induced by triggers such as accidental overdose or introduction of an interacting agent. Cutaneous ulceration typically precedes other markers of toxicity. Active treatment with folinic acid (calcium leucovorin) may be required. Early recognition, prompt cessation of methotrexate, and appropriate treatment minimizes morbidity. Dermatologists need to be alert to the possibility of cutaneous adverse events associated with methotrexate therapy, aware of potential drug interactions, and confident in the management of methotrexate toxicity.Electronic supplementary materialThe online version of this article (doi:10.1007/s13555-014-0056-z) contains supplementary material, which is available to authorized users.

Critical appraisal of adalimumab in the treatment of chronic plaque psoriasis

Critical appraisal of adalimumab in the treatment of chronic plaque psoriasis

Broadband ultraviolet A in the treatment of psoriasis vulgaris: a randomized controlled trial

Broadband ultraviolet A (BB-UVA) has been successfully used in the treatment of scleroderma, a UVA1-responsive dermatosis. To compare the efficacy of BB-UVA versus psoralen+UVA (PUVA) in psoriasis treatment and assess apoptosis as an effector mechanism. This randomized controlled trial included 61 patients with chronic plaque psoriasis randomly divided into group I or II. Group I were further randomized to either IA or IB who received UVA 10 or 15J/cm(2) per session, respectively, while group II received PUVA. Therapy was delivered thrice weekly until clearance or 48 treatments at most. The primary outcome measured was clearance of psoriasis. Dermal lymphocytic counts and bcl-2 expression were measured in 20 patients from each group. Final Psoriasis Area Severity Index scores were reduced within each group. The UVA group achieved results comparable to PUVA until session 24 but failed to match it at final evaluation, with significantly better clinical, immunohistochemical, and histopathological results achieved by PUVA (P≤0.05). Both modalities caused a reduction in dermal lymphocytic counts and epidermal bcl-2 expression. BB-UVA appears to be safe and acceptable for the treatment of chronic plaque psoriasis possibly through bcl-2-mediated apoptosis of keratinocytes and epidermal lymphocytes.

The Cost Effectiveness of Biologic Therapy for the Treatment of Chronic Plaque Psoriasis in Real Practice Settings in Italy

Background and ObjectivesBiologic therapies are considered to be cost effective by leading Health Technology Assessment (HTA) agencies and, therefore, eligible for reimbursement by public health services. However, biologic therapies entail sizable incremental costs and, besides, have a considerable financial impact that in Italy amounts to 13.7 % of the national health service’s pharmaceutical expenditure. In the reimbursability decision process, an important role is played by both the drug efficacy data observed in pre-licensing RCTs and the economic modelling assumptions, as they give evidence on cost effectiveness. The administration of therapies in real practice settings is likely to produce a significant deviation from the results predicted by the models, theoretically outweighing the assumption on which the decision process is founded. This is a matter of concern for public health services and, consequently, an interesting topic to investigate.MethodsTo overcome the lack of knowledge concerning the actual cost effectiveness of biologic therapies for the treatment of plaque psoriasis in the clinical practice setting in Italy, an observational study was conducted in 12 specialist centres on patients switching to biologic therapy within a 6-month enrolment window.ResultsThe study confirms in clinical practice the efficacy of the switch to biologic therapies, analysed using a number of clinical [Psoriasis Area and Severity Index (PASI), pain visual analogue scale (VAS) and itching VAS] and quality-of-life parameters. A general health-related quality of life (HR-QOL) improvement, with a 0.23 quality-adjusted life-year (QALY) mean gain per patient, has been reported in the 6-month observation period. The direct medical costs to treat plaque psoriasis with biologic therapies amount to €15,073.7 per year (prior to their enrolment, the same patients cost €2,166.2 on an annual basis). After the switch to biologic agents, the cost per QALY during the first year of treatment amounts to €28,656.3.ConclusionAt least in the short-term, the clinical practice of the specialised Italian centres taking part in the study confirms that switching patients to a biologic drug produces an incremental cost-effectiveness ratio comparable with the values predicted by the HTA bodies.

Recalcitrant psoriasis responding to new bilogic drug: Ustekinumab

Recalcitrant psoriasis responding to new bilogic drug: Ustekinumab

Topical treatments for chronic plaque psoriasis: An abridged Cochrane Systematic Review

Chronic plaque psoriasis is the most common type of psoriasis and is characterized by redness, thickness, and scaling. First-line management is with topical treatments. We sought to undertake a Cochrane review of topical treatments for chronic plaque psoriasis. We systematically searched major databases for randomized controlled trials. Trials reported improvement using a range of related measures; standardized, pooled findings were translated onto a 6-point improvement scale. The review included 177 randomized controlled trials with 34,808 participants, including 26 trials of scalp psoriasis and 6 trials of inverse and/or facial psoriasis. Typical trial duration was 3 to 8 weeks. When compared with placebo (emollient base), the average improvement for vitamin-D analogues and potent corticosteroids was approximately 1 point, dithranol 1.2 points, very potent corticosteroids 1.8 points, and combined vitamin-D analogue plus steroid 1.4 points once daily and 2.2 points twice daily. However, these are indicative benefits drawn from heterogeneous trial findings. Corticosteroids were more effective than vitamin D for treating psoriasis of the scalp. For both body and scalp psoriasis, potent corticosteroids were less likely than vitamin D to cause skin irritation. Reporting of benefits, adverse effects, and safety assessment methods was often inadequate. In many comparisons, heterogeneity made the size of treatment benefit uncertain. Corticosteroids are as effective as vitamin-D analogues and cause less skin irritation. However, further research is needed to inform long-term maintenance treatment and provide appropriate safety data.