Scalp psoriasis: a review of current topical treatment options.

The scalp is the most common site of disease involvement at the onset and throughout the course of psoriasis. For many patients, psoriasis of the scalp is the most difficult aspect of their disease; yet, despite a wide range of therapy options and an extensive literature base, scalp psoriasis remains difficult to treat, highlighting a long-standing unmet need for the effective treatment of scalp psoriasis. A review of past and current medical literature reveals that a number of interesting therapeutic approaches have been used in the treatment of scalp psoriasis. The diverse and sometimes extreme therapeutic approaches, the marginal benefit of many topical agents, the paucity of controlled studies evaluating the efficacy of topical agents in the treatment of scalp psoriasis and the high level of patient dissatisfaction with currently available treatments for psoriasis all support the need for new, effective and well-tolerated treatment options for scalp psoriasis.

Folic acid supplementation during treatment of psoriasis with methotrexate: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: The value of folate supplementation in methotrexate (MTX)-treated patients remains controversial. OBJECTIVES: To determine the effect of folic acid (FA) on the efficacy of MTX and the frequency of side-effects associated with MTX therapy. METHODS: A 12-week double-blind clinical trial was conducted in patients with psoriasis stable on their long-term MTX doses but not receiving FA. They were randomized into two arms of either FA 5 mg or placebo daily. MTX doses were not changed throughout the study. Patients were monitored every 3 weeks by the same observer. Assessments included Psoriasis Area and Severity Index (PASI), a visual analogue scale (VAS) of patients' perception of their psoriasis severity and the Dermatology Life Quality Index (DLQI). Adverse events were systematically recorded. Haematological and biochemical monitoring was performed. RESULTS: Twenty-two patients with psoriasis were recruited. Age, sex and weekly MTX doses were similar in both groups. All 22 patients completed the study. The mean PASI in the FA group increased from 6.4 at baseline to 10.8 at 12 weeks. In the placebo group the mean PASI fell from 9.8 at baseline to 9.2 at 12 weeks. The mean change from baseline in the FA group was 4.4 vs. -0.6 in the placebo group (P < 0.05). Similar trends were observed in the changes in VAS and in the DLQI and differences between the groups were significant for both these parameters (P < 0.05). Few adverse effects were reported. CONCLUSIONS: This study suggests that supplementation with FA during long-term MTX treatment reduces the efficacy of MTX in the control of psoriasis. Due to the relatively small sample size and short duration of this study, no conclusions can be drawn regarding the possibility that FA may reduce the side-effects of MTX.

Efficacy and tolerability of borage oil in adults and children with atopic eczema: randomised, double blind, placebo controlled, parallel group trial.

OBJECTIVE: To study the efficacy and tolerability of borage oil, which contains a high concentration of gamma linolenic acid, in children and adults with atopic eczema. DESIGN: Single centre, randomised, double blind, placebo controlled, parallel group trial. SETTING: Acute district general hospital in Nuneaton, England. PARTICIPANTS: 151 patients, of whom 11 failed to return for assessment, leaving an evaluable population of 140 (including 69 children). INTERVENTION: Adults received four capsules of borage oil twice daily (920 mg gamma linolenic acid), and children received two capsules twice daily, for 12 weeks. MAIN OUTCOME MEASURES: Change in total sign score at 12 weeks measured with the six area, six sign, atopic dermatitis (SASSAD) score (primary endpoint); symptom scores, assessed on visual analogue scales; topical corticosteroid requirement, assessed on a five point scale; global assessment of response by participants; adverse events and tolerability. RESULTS: The mean SASSAD score fell from 30 to 27 in the borage oil group and from 28 to 23 in the placebo group. The difference between the mean improvements in the two groups was 1.4 (95% confidence interval -2.2 to 5.0) points in favour of placebo (P = 0.45). No significant differences occurred between treatment groups in the other assessments. Subset analysis of adults and children did not indicate any difference in response. The treatments were well tolerated. CONCLUSION: Gamma linolenic acid is not beneficial in atopic dermatitis.

High dose topical calcipotriol consistently reduces serum parathyroid hormone levels.

OBJECTIVE: Calcipotriol is a vitamin D analogue which is an effective topical treatment for chronic plaque psoriasis. It has been reported to have no effect on systemic calcium homeostasis provided the manufacturer's guidelines are adhered to (maximum 100 g of calcipotriol ointment (50 micrograms/g) per week). However, there have been reports of hypercalcaemia in patients using topical calcipotriol even at recommended doses. The purpose of this study was to investigate the effects of topical calcipotriol in vivo using the recently developed 'intact' PTH assay as a more sensitive index of systemic calcium homeostasis. DESIGN AND PATIENTS: Seven patients with extensive psoriasis were recruited for the study. Each patient was admitted to hospital and applied 200 g of calcipotriol (50 micrograms/g) ointment over the first week followed by 300 g over the second week. In the third week of treatment, patients were treated with 2% crude coal tar which served as a biochemical washout phase. MEASUREMENTS: Serum total adjusted calcium was measured at baseline and three times a week during the study. Twenty-four-hour urinary calcium excretion was measured at baseline and twice a week throughout the study. Peak (0400 h) and trough (0900 h) PTH levels were measured at baseline and at the ends of weeks 2 and 3. RESULTS: Serum PTH levels were reduced in every patient after 2 weeks' treatment with calcipotriol and rose after withdrawal. Mean 0400 h PTH fell by 2.58 pmol/l (95% confidence interval 1.45-3.70) from 5.11 to 2.53 pmol/l (P < 0.01) and mean 0900 h PTH fell by 2.08 pmol/l (0.84-3.36) from 4.04 to 1.96 pmol/l (P < 0.01). Mean serum and urine calcium rose during treatment with calcipotriol and fell after withdrawal. Mean adjusted total calcium rose by 0.14 mmol/l (95% confidence interval 0.10-0.16) from 2.25 to 2.39 mmol/l (P < 0.01). Mean 24 hour urine calcium excretion rose by 2.09 mmol/24 h (0.51-3.26) from 3.40 to 5.49 mmol/24 h (P < 0.05). No patient developed hypercalcaemia at any stage of the study although hypercalcaemia was recorded transiently in three patients. CONCLUSION: Topical calcipotriol is likely to have a dose dependent effect on systemic calcium homeostasis.

High-dose topical calcipotriol in the treatment of extensive psoriasis vulgaris.

Ten patients with extensive plaque psoriasis were treated with calcipotriol ointment (50 micrograms/g) for 2 weeks (200 g for 1 week, followed by 300 g during the second week). Mean improvement in psoriasis area and severity index (PASI) was 71%. Mean 24 h urine calcium rose from 4.79 mmol/24 h to 7.27 mmol/24 h (P < 0.0001). Urine calcium returned towards baseline after stopping calcipotriol. Mean serum calcium also rose slightly, but significantly, from 2.26 mmol/l to 2.32 mmol/l (P < 0.005), and fell again in the washout phase. Individual serum calcium values remained within the normal range throughout the study. Topical calcipotriol is an effective, rapidly acting and safe in-patient treatment for extensive plaque psoriasis.

Placebo-controlled trial of essential fatty acid supplementation in atopic dermatitis.

Treatment of atopic dermatitis with essential fatty acids remains controversial. A double-blind, placebo-controlled, parallel-group study was done to investigate the response of patients with atopic dermatitis to essential fatty acid supplements. Patients with atopic dermatitis were randomised to receive evening primrose oil, evening primrose oil and fish oil, or placebo for 16 weeks. Disease activity was monitored by clinical severity scores recorded by the investigator, topical steroid requirement, and symptom scores recorded by subjects. Of 123 subjects recruited, 102 completed the treatment period. No improvement with active treatment was demonstrated. Our study, which avoided the methodological and analytical problems of previous studies, found no effect of essential fatty acid supplementation in atopic dermatitis.

Neurological complications of systemic sclerosis--a report of three cases and review of the literature.

We report three cases of systemic sclerosis demonstrating four different neurological complications: trigeminal neuropathy, peripheral neuropathy, carpal-tunnel syndrome and prolonged response to local anaesthesia. A review of the literature reveals a wide range of neurological abnormalities associated with systemic sclerosis. When they occur, these are often presenting features.