topical therapies for the treatment of plaque psoriasis

7/28/2019 Topical Therapies for the Treatment of Plaque Psoriasis

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Created By :

Masrida Rezki (2008730086)Adviser :

dr. Bowo Wahyudi, Sp.KK

Dermatovenereology RSUD Banjar

Universitas Muhammadiyah Jakarta


2/15

Psoriasis

Psoriasis is a common chronic inflammatory skin

condition and, although generally not life threathening, it

can have a profound impact on physical, physicological

and social well-being.

Nearly 80% patients with psoriasis is

plaque psoriasis.

The skin changes in patients with

psoriasis takes place rapidly at about

2-4 days, (it can even happen faster)

that a lot of skin cell turnover and

thickened.


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Psoriasis Treatment

The psoriasis treatment is there

only to suppress the symptoms,

improve skin condition, relieves

itch.

Psoriasis treatment is usually done in a variety of ways

starting with a topical treatment, systemic or by irradiation

with UVB rays. Both treatments only help reduce the disease and

do not heal at all, so any time the disease can recur.


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Backgrounds

Investigator set out to summarize evidence the relative efficacy,

safety and tolerability of different topical treatments used in plaque

psoriasis.

While recent advances and investment in high-cost biological

therapies have revolutionized outcomes for people with severe disease

, comparatively little attention has been paid to topical therapy,

which forms the cornerstone of management for the majority of people

with psoriasis.

Finally, they undertook a systematic review and meta-analysis of

randomized trial data of U.K licensed topical therapies.


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Objective

i. To summarize the evidence on topical treatments in

chronic plaque psoriasis (stratified for trunk and limbs,

and scalp) to allow comparison of their efficacy,

tolerability and safety

ii. To synthesize data on efficacy to inform original cost-

effectiveness modelling


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Search strategy and selection criteria

Abstracts were screened and articles that appeared to meet

the inclusion criteria were assessed further. Studies were

excluded if they were not published as full reports, due to

high risk of bias.

Eligible studies were required to have at least 25 people in

each study arm and to report induction or maintenance of

remission.

The unit of randomization could be the individual patients or

one side of the body.


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Interventions

Vitamin D and vitamin D

analogue

Potent or very potent

corticosteroids

Combination of vitamin D andpotent corticosteroids either as

a TCF or TCA

Tar

Dithranol

Retinoids

The primary outcome was the

proportion of patients achieving

clear or nearly clear status on

either the Investigators

Assesment of Overall Global

Improvement (IAGI) or dynamic

Physicians Global Assessment(PGA) or static PGA.

The secondary outcome was

clear or nearly clear status as

assessed by either the Patients

Assessment of Overall Global(PAGI) or the staticspatients

Global Assessment.

Outcomes


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Statistical Analysis

Data were stratified according to the site of psoriasis : (i) trunk

and limbs; and (ii) scalp.

A series of pairwise meta-analyses for the primary and secondary

outcome for induction of remission produced 12 direct comparisons for

trunk and limb psoriasis and 10 for scalp psoriasis.

The analysis was performed in WinBUGS 19 using a multi-arm, random

effects logistic regression model, with parameter estimated by Markov

chain Monte Carlo Simulation.


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Results


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Results

For trunk and limb psoriasis approximately half of the studies included

populations with moderate to severe psoriasis assessed by PASI, PGA or

BSA, while others included either mild to moderate psoriasis, any disease

severity as an inclusion criterion. For scalp psoriasis, the majority of studies included those with moderate to

severe scalp involvement, with three stipulating mild to moderate scalp

disease and three allowing any severity any severity to be included.

In pairwise result, the most rapid improvement in response occured during

the first 2-4 weeks for corticosteroids, and the first 4 weeks for vitamin D

analogue containing intervention, dithranol, and coal tar.


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Results

In NMA results for trunk and limb psoriasis, all active interventions were

significantly more effective than placebo twice daily, except coal tar used

once daily and retinoids. Very potent steroids were the most effective

treatment option.


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Results

The TCF product was significantly more effective than once daily application of

vitamin D analogues, potent corticosteroids, retinoids or coal tar.

In NMA results for scalp psoriasis, all active interventions were more efficacious

than placebo applied twice daily, although there was uncertainty about this coal tar

shampoo and vitamin D analogues used once daily. As with psoriasis trunk and limbs,

very potent steroids were the most effective treatment option.


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Results

Considering comparisons between different active interventions, very few

demonstrated a statistically significant difference. Exceptions were that once daily

and very potent corticosteroids were significantly better than vitamin D regardless of

frequency of application.

One study for scalp and one for trunk and limb psoriasis suggested that the relapse

rate was greater for interventions containing steroids compared with vitamin D

analogues.

There was no statistically significant increased risk of steroid atrophy with

corticosteroid use compared with other interventions, although the majority of cases

of steroid atrophy reported did occur in people who received corticosteroids, and

greater numbers of withdrawals due to adverse effects were seen with twice-daily

potent corticosteroid compared with once-daily use.


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Discussion

Overall, the NMA hierarchy of effectiveness for topical therapy for trunk and

limb psoriasis indicated that discounting very potent steroids, the

combination of potent corticosteroid and vitamin D analogue, either applied

once daily in a single TCF product or applied separately, was the mosteffective intervention, with no significant difference between these

application methods.

The rank order of efficacy for the scalp almost similar. Very potent steroids

were the most effective treatment and vitamin D analogues and coal tar

shampoo were the least effective overall.


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Discussion

Strengths of this study include the additional power afforded by

synthesizing all of the available data in one coherent network.

A recognized limitation of this analysis is that for the majority of trunk and

limb studies included, the severity of psoriasis was recorded as moderate tosevere.

Presence or absence of steroids atrophy was a key outcome in only a

minority of studies and no study used validated objective measures for

assessment.

topical therapies for the treatment of plaque psoriasis

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