Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology

Abstract: Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian population. The most common clinical manifestations are erythematous, scaling lesions that affect both genders and can occur on any anatomical site, preferentially involving the knees, elbows, scalp and genitals. Besides the impact on the quality of life, the systemic nature of the disease makes psoriasis an independent risk factor for cardiovascular disease, especially in young patients with severe disease. By an initiative of the Brazilian Society of Dermatology, dermatologists with renowned clinical experience in the management of psoriasis were invited to form a work group that, in a partnership with the Brazilian Medical Association, dedicated themselves to create the Plaque Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the diagnosis (evaluation of severity and comorbidities) and treatment of plaque psoriasis were defined. The issues generated a search strategy in the Medline-PubMed database up to July 2018. Subsequently, the answers to the questions of the recommendations were devised, and each reference selected presented the respective level of recommendation and strength of scientific evidence. The final recommendations for making up the final text were worded by the coordinators.

Combination of excimer laser and topical treatment for psoriasis: A systematic review and meta-analysis

@#<p style="text-align: justify;"><strong>OBJECTIVES: </strong>To assess the efficacy and safety of excimer laser in combination with topical standard therapies for treatment of plaque-type psoriasis in comparison to excimer laser alone, standard topical treatment alone, or placebo.</p><p style="text-align: justify;"><strong>METHODS: </strong>A literature search using Medline, Cochrane and HERDIN was conducted. Data were analyzed using mean difference at 95% confidence interval, with heterogeneity determined by I2 test.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Three articles with total of 130 patients fulfilled the inclusion criteria. Topical treatments studied were vitamin analog (calcipotriol), anthralin (dithranol), and steroid (flumethasone pivalate). A subgroup analysis comparing combination therapy and excimer laser alone showed a greater reduction in pooled PASI score reduction (-2.52; 95% CI: -4.28, -0.77) in the combination group after five to six weeks. There was also a significantly greater reduction in cumulative UVB dose (-3.29; 95% CI: -4.29, -2.30) needed for clearing in the combination group. Pigmentation was the commonly observed adverse event in both groups.</p><p style="text-align: justify;"><strong>CONCLUSIONS:</strong> Excimer laser, in combination with topical treatment, is more effective than excimer laser alone, with significantly lower cumulative UVB dose, but the quality of current evidence is low. Long-term controlled trials are warranted to increase our confidence in the estimates of these outcomes.</p>

Use of solid dispersions to increase stability of dithranol in topical formulations

The present study was planned to improve the stability of dithranol using solid dispersions (SD). Two different SD at a 1:9 ratio of dithranol/excipient were prepared: one of them using glyceryl behenate as excipient and the other using a mixture of argan oil with stearic acid (1:8 ratio) as excipient. Pure dithranol and SD of dithranol were incorporated in an oil-in-water cream and in a hydrophobic ointment in a drug/dermatological base ratio of 1:10. The physical and mechanical properties of semisolid formulations incorporating the pure drug and the developed SD were evaluated through rheological and textural analysis. To evaluate the stability, L*a*b* color space parameters of SD and semisolid formulations, and pH of hydrophilic formulations were determined at defined times, during one month. Each sample was stored at different conditions namely, light exposure (room temperature), high temperature exposition (37 °C) (protected from light) and protected from light (room temperature). Despite higher values of firmness and adhesiveness, hydrophobic ointment exhibited the best rheological features compared to the oil-in-water cream, namely a shear-thinning behavior and high thixotropy. These formulations have also presented more stability, with minor changes in L*a*b* color space parameters. The results of this study indicate that is possible to conclude that the developed SD contributed to the increased stability of dithranol.

Este trabalho teve como objetivo aumentar a estabalidade do ditranol através da preparação de dispersões sólidas (DS). Prepararam-se duas DS diferentes em proporção de 1:9 de ditranol/excipiente: em uma das DS utilizou-se beenato de glicerila como excipiente e na outra se utilizou mistura de óleo de argan com ácido esteárico (razão 1:8). Posteriormente, efetuou-se a incorporação de ditranol puro e das DS contendo este fármaco num creme hidrófilo ou óleo-água (O/A) e em pomada hidrófoba, na proporção 1:10 (fármaco ou respetivas DS/base dermatológica). As propriedades físicas e mecânicas das formulações semissólidas incorporando fármaco ou as respetivas DS previamente desenvolvidas, foram avaliadas através da análise do comportamento reológico e das propriedades de textura. Para avaliar a estabilidade, os parâmetros do espaço de cor L*a*b* das DS e das formulações semissólidas e o pH das preparações hidrófilas foram determinados em períodos de tempo definidos, durante um mês para cada amostra armazenada sob diferentes condições, especificamente, exposição à luz (à temperatura ambiente), protegidas da luz à temperatura elevada (37 °C) e protegidas da luz (temperatura ambiente). Embora tenham apresentado valores de firmeza e de adesividade mais elevados, as pomadas hidrófobas apresentaram melhores características reológicas do que os cremes óleo-água. Além disso, as pomadas hidrófobas também apresentaram melhor estabilidade, com pequenas alterações nos parâmetros do espaço de cor L*a*b*. Os resultados deste trabalho permitiram concluir que as DS desenvolvidas contribuíram para o aumento da estabilidade do ditranol.

Statistical optimization of dithranol-loaded solid lipid nanoparticles using factorial design / Otimização estatística de nanopartículas lipídicas sólidas carregadas com ditranol utilizando planejamento fatorial

This study describes a 3² full factorial experimental design to optimize the formulation of dithranol (DTH) loaded solid lipid nanoparticles (SLN) by the pre-emulsion ultrasonication method. The variables drug: lipid ratio and sonication time were studied at three levels and arranged in a 3² factorial design to study the influence on the response variables particle size and percent entrapment efficiency ( percentEE). From the statistical analysis of data polynomial equations were generated. The particle size and percentEE for the 9 batches (R1 to R9) showed a wide variation of 219-348 nm and 51.33- 71.80 percent, respectively. The physical characteristics of DTH-loaded SLN were evaluated using a particle size analyzer, differential scanning calorimetry and X-ray diffraction. The results of the optimized formulation showed an average particle size of 219 nm and entrapment efficiency of 69.88 percent. Ex-vivo drug penetration using rat skin showed about a 2-fold increase in localization of DTH in skin as compared to the marketed preparation of DTH.

Este estudo descreve o planejamento factorial 3² para otimizar a formulação de nanopartículas lipídicas sólidas (SLN) carregadas com ditranol (DTH) pelo método da ultrassonificação pré-emulsão. As variáveis como proporção de fármaco:lipídio e o tempo de sonicação foram estudados em três níveis e arranjados em planejamento fatorial 3² para estudar a influência nas variáveis de resposta tamanho de partícula e eficiência percentual de retenção do fármaco ( por centoEE). Pela análise estatística, geraram-se equações polinomiais. O tamanho da partícula e a por centoEE para os 9 lotes (R1 a R9) mostraram ampla variação, respectivamente, 219-348 nm e 51,33-71,80 por cento. As características físicas das SLN carregadas com DTN foram avaliadas utilizando-se analisador de tamanho de partícula, calorimetria de varredura diferencial e difração de raios X. Os resultados da formulação otimizada mostraram tamanho médio de partícula de 219 nm e eficiência de retenção do fármaco de 69,88 por cento. A penetração ex vivo do fármaco utilizando pele de rato mostrou aumento de, aproximadamente, duas vezes na localização de DTH na pele, comparativamente à preparação de DTH comercializada.

Therapeutic Effect of Topical Anthralin for Treatment-Resistant Extensive Alopecia Areata / 대한피부과학회지

BACKGROUND: Extensive alopecia areata (EAA) is resistant to multiple individual treatment modalities and has poor prognosis for cosmetically adequate regrowth. Anthralin is a widely used topical anti-psoriatic drug that may have an immunomodulating effect on AA as is does in psoriasis. But, there has only been small number of clinical trials of anthralin in the treatment of AA. OBJECTIVE: The purposes of the study were to evaluate the efficacy, prognostic factor, side effects and recurrence rate of topical anthralin therapy in treatment-resistant EAA. METHODS: A total of 16 cases of EAA (>50% scalp hair loss) who had failed in previous treatments were subjected in this study. Anthralin in 0.5% concentrations was applied to alopectic lesions for 1 hour daily over 4 weeks, gradually increasing anthralin concentration until low-grade erythema and pruritus develops. Treatment was withdrawn after complete response or if there were no signs of improvement at 6 months. Responders were followed up for 6 months after discontinuation of therapy. RESULTS: The overall response rate was 62.5%, complete response (>90% regrowth or cosmetically acceptable appearance) was obtained in 25% of cases and, good response (50~99% regrowth) in 39.5% of cases. In this study, among the investigated prognostic factors, there were no statistically significant factors (p<0.05, Fisher exact test). The most frequent side effects were therapeutically induced mild pruritus (93.8%), erythema (93.8%) and scale (56.3%). Other side-effects were transient folliculitis (31.3%) and regional lymph adenopathy (12.5%). Relapse was observed in 60% of responders after 6 month of follow up. CONCLUSION: Topical anthralin for treatment-resistant EAA is an effective therapy with tolerable side effects. Therefore, we propose the topical anthralin as a reasonable therapeutic option for treatment-resistant EAA.

Two Cases of Alopecia Areata Treated with Anthralin / 대한피부과학회지

Alopecia areata (AA) is a recurrent, nonscarring type of hair loss. Although it is a medically benign condition, AA can cause great emotional distress to affected patients and their family. At this time, there are many treatments that have varying efficacies but there is no reliable cure. Topical anthralin treatment of AA has been found to be effective by some researchers. We experienced two cases of AA improved by topical anthralin therapy without serious side effects. Anthralin is much less expensive than most other topical therapies for AA and relatively well tolerated. In our experience, it is more effective in eliciting a cosmetic response than other topical treatments. Anthralin appears to be a reasonable therapeutic option for AA.

Tratamiento de la psoriasis infantil / Treatment of infant psoriasis

La psoriasis constituye el 4-5 porciento de todas las dermatosis que afectan a los menores de 16 años. Su tratamiento en los niños constituye un verdadero desafío para el médico, ya que se desconoce la real efectividad e inocuidad en este grupo de edad de muchos de los fármacos utilizados. Además, tampoco han sido completamente estudiados los posibles efectos a largo plazo que puede tener el uso de ciertos medicamentos. El tratamiento de esta entidad clínica durante la infancia exige una evaluación individual y una adaptación de éste a cada paciente en particular, considerando una gran cantidad de factores. La educación del niño y su familia es esencial en presencia de esta enfermedad de naturaleza crónica y de evolución imprevisible. En la mayoría de los casos, la psoriasis se controla con tratamientos tópicos. Los tratamientos sistémicos se reservan sólo para casos graves y rebeldes, ya que éstos presentan una mayor cantidad de efectos secundarios, los que pueden ser de especial gravedad en los niños. Afortunadamente, en la mayoría de los pacientes, el seguimiento de ciertas medidas generales y de las pautas de tratamiento determinará un adecuado control de la enfermedad. En el presente artículo se discuten las indicaciones de los diversos fármacos disponibles para el control de la psoriasis durante la infancia, tanto tópicos como sistémicos. Se hace especial hincapié en la efectividad que han demostrado en niños, y los posibles efectos secundarios específicos que pueda acarrear su utilización en este grupo de edad

Revisión de los conocimientos actuales sobre alopecia areata / Review of updated knowledge about alopecia areata

La alopecia areata (AA) es una enfermedad frecuente que provoca serios trastornos estéticos y psicológicos a los individuos afectados. Aunque su etiología no ha sido bien aclarada, las últimas investigaciones apuntan hacia una causa autoinmune. Los tratamientos disponibles hasta la fecha son sólo paliativos y no cambian el curso de la enfermedad. La presente revisión tiene como objetivo dar a conocer los conceptos actuales sobre aspectos epidemiológicos fisiopatológicos y clínicos de la AA. Se revisan los medicamentos más utilizados en su tratamiento y esquemas terapéuticos propuestos

Tratamiento de la alopecia areata / Treatment of the alopecia areata

En una patología como la alopecía areata, la que se presenta de distintas formas clínicas, con asociaciones variadas, donde las remiciones son posibles y los tratamientos disponibles no son 100 por ciento eficaces, es dificil evaluar la terapéutica más adecuada. lLos tratamientos disponibles pueden dividirse en tópicos y sistémicos. Los corticoides ocupan un lugar importante en el arsenal terapéutico, en especial los tópicos o en inyecciones intralesionales. Otrs productos se usan con resultados varioables como la inminoterapia tópica, en especial con el minoxidil, la difenciprona y la antralina. La medicación sistïrmica se reserva para casos severos (corticosteroides,ciclosporina A, etc). La mayoría actuarían alterando la respuesta inmune y en otros en controvertida. Consideramos a la afección dentro de su marco general, más que etético, pero sin descuidar la integridad del individuo y hacia esto debemos apuntar en nuestra estrategia de tratamiento. La relación paciente-médico es fundamental para manejar esta enfermedad en la que aún no tenemos una medicación curativa.

Terapéutica de la psoriasis / Therapy for psoriasis

La psoriasis es una enfermedad de la piel que está caracterizada por su naturaleza crónica con recaídas y una gran variedad de manifestaciones cutáneas. Afecta aproximadamente entre el 1 y 2 por ciento de la población y aparece generalmente en la tercera década de la vida. La patogenia de la enfermedad no se comprende en su totalidad, pero dos mecanismos parecen ser importantes: la proliferación epidérmica y el proceso inflamatorio. Precisamente porque se desconoce la causa, múltiples tratamientos se han propuesto. En este trabajo se realiza una revisión sobre los tratamientos, tanto tópicos como sistémicos, haciendo énfasis en los mecanismos de acción, dosificación, efectos secundarios y las terapias de combinación más efectivas utilizadas para el tratamiento de esta enfermedad

The Effectiveness and Remission Time of Modified Ingram Therapy for Psoriasis / 대한피부과학회지

BACKGROUND: The Ingram regimen has been advocated for t.he treatment of psoriasis. It is an effective therapeutic moiality, but its complexity and frequent side reactions have restricted its use for therapy. There are several modified Ingrarn regimen, change of vehicle, shortening of application time, low-strerigth anthralin, combination with emollient. Previously, we have reportved the effectiveness of mocified Ingram regimen for psoriasis, however, the remission time and relapse rate of psoriasis has not been reported in Korea. OBJECTIVE: This study was performed to evaluate the efficacy of the modified Ingram region for the treatment of psoiasis and the remission time and relapse rate of psoriasis following moclified Ingram therapy. METHODS: Sixty patients with plaque-form psoriasis were treated with the modified Ingra,n therapeutic regimen. They were divided into two groups, a moderate group which included 39 patients, and 21 patients in a severe group. RESULTS: The follwing results were obtained from this study. 1. Among 60 patients, 52 patients(86.6%) were successfully healed and 8 patients(13.3%) showed failure in their t eatment. 2. In 52 patients, 44 patients(73.3%) showed a clearing of psoriasis, 8 patients(13.3%) showed some improvement. 3. In 44 cleared patients mean numbers and duration of therapy reaching grade 4 were 13.0 and 21.0 days for the trunk and 15.1 and 24.7 days for the extremities, the difference was not significant statistically(p>0.05). The difference between the total dose in trunk and extremitis was significant statistica,ly(p6 months) and 14(60.9%) with riorelapse(>12 months) in the moderate group and also observed 10 patients(70.0%) with early IP, lapse, 2(20.0%) with latrelapse and 1(10.0%) with no relapse in the severe group. 7. In 33 pat,ients who were followed up at least one year later, the mean time of remission was 31.4 months in the moderate group and 6.0 mont,hs in the severe group. There were signilicant differences in the two groups(p<0.05). CONCLUSION: The results of this study suggest that the modified Ingram regimen is one of the effective therapeutic mocialities for cases of moderate psoriasis.

Alopecía areata: tratamiento / Alopecia areata: treatment

El tratamiento de la alopecía areata ha cambiado notablemente en la última década. Nuevas opciones terapéuticas están disponibles para los pacientes. Es deber del dermatólogo informar al paciente de todas las alternativas posibles para su caso, sus efectos colaterales y sus cifras de éxito. La decisión final es conjunta, entre el paciente, la familia del paciente (cuando corresponda) y el dermatólogo

Aspectos clínicos de la alopecia areata: tratamiento tópico comparativo entre antralina y betametasona / Clinical aspects of the alopesia areata: comparative topical treatment between anthralin and betamethasane

En forma prospectiva se estudiaron los aspectos clínicos de 53 pacientes con alopecia areata. Las asociaciones más frecuentes fueron el estrés emocional agudo, los antecedentes familiares y los antecedentes personales de la enfermedad. Se realizó un estudio terapéutico comparativo entre antralina y betametasona tópica, resultando superior la antralina en forma estadísticamente significativa