Guidelines for management of androgenetic alopecia based on BASP classification--the Asian Consensus Committee guideline.

BACKGROUND: Androgenetic alopecia (AGA), or pattern hair loss, is a common disorder in both Asian men and women. There are several guidelines for the treatment of AGA which are suitable for Caucasian patients; however, each of these has some limitations. Furthermore, in comparison with Caucasian patients, Asian patients with AGA have different types of hair loss and family histories which may alter the treatment response. There is currently no published AGA guideline for Asian patients. OBJECTIVES: The Asian Consensus Committee for Androgenetic Alopecia aimed to develop an algorithmic guideline, based on the basic and specific (BASP) classification, for the treatment of AGA especially in Asian patients. METHODS: The committee collaborated extensively on reviewing available literature on AGA treatment in order to formulate an algorithmic guideline on AGA management. RESULTS: Previously published guidelines based on pre-existing classifications of AGA cannot easily classify the patterns of AGA that are more frequently seen in Asians. The BASP classification not only facilitates the development of a unified and simplified algorithm, but also overcomes the disadvantages of previously reported classification systems. CONCLUSIONS: The proposed treatment guideline for AGA based on the BASP classification may be useful for dermatologists in their approach to treating Asian patients with AGA in clinical practice. Ideally, clinicians should try to utilize this guideline consistently in their practice to monitor treatment response with the goal of enhancing successful outcomes. This will help boost patients' confidence and self-esteem, thus improving patient' compliance with the prescribed treatments.

Accuracy of preoperative CT for local staging in colorectal carcinomas.

INTRODUCTION: This study aimed to determine the accuracy of computed tomography (CT) in the evaluation of local tumour invasion and regional lymphadenopathy in colorectal carcinomas. METHODS: A total of 99 consecutive patients who had undergone a contrast-enhanced CT within two weeks prior to surgery with histopathological confirmation of colorectal carcinoma were selected. Intravenous contrast-enhanced CT was performed with a 5-7 mm collimation. Axial images were retrospectively and independently reviewed by two radiologists (R1 and R2) who were blinded to the surgical findings and histopathology. The readers assessed the primary tumour according to modified CT staging criteria. The radiological assessment was then compared with the surgical findings and histopathology for accuracy and inter-observer agreement. RESULTS: At histopathology, the T-stage of the tumours was T2 in five, T3 in 62 and T4 in 32 patients, and the N-stage was N0 in 36, N1 in 28 and N2 in 35 patients. The accuracy of CT for T-stage and N-stage for the two readers was 45.5 percent and 60.6 percent (kappa is 0.30) and 33.3 percent and 45.4 percent (kappa is 0.23), respectively. The understaging and overstaging by R1 and R2 was 40.4 percent, 21.2 percent and 14.1 percent, 17.2 percent for T-stage and 22.2 percent, 37.4 percent and 32.3 percent, 28.3 percent for N-stage. The accuracy of serosal invasion for R1 and R2 (tumour perforates the visceral peritoneum or directly involves the adjacent organs) was 63.6 percent and 66.7 percent (kappa is 0.51), respectively. The understaging and overstaging by R1 and R2 for serosal invasion was 24.1 percent, 12.1 percent and 20.1 percent, 12.1 percent, respectively. CONCLUSION: Our study results show that the accuracy for CT staging of colorectal carcinomas for T-stage and in particular, serosal invasion, is moderate, but it is relatively low for N-stage.

Hand-assisted laparoscopic abdomino-perineal resection utilizing the planned end colostomy site.

BACKGROUND: Aim of the study was to determine the feasibility and outcomes of utilizing the planned end colostomy site for placing the hand-assist device in performing hand-assisted laparoscopic abdominoperineal resections (HAL APR) in patients with low rectal cancer. METHODS: Patients with low rectal cancers not suitable for a sphincter salvage proctectomy were recruited. HAL APR was performed by placing the hand-assist device over the planned colostomy site. Standard total mesorectal excision (TME) was performed, and the specimen was delivered via the perineal incision. Patient data and perioperative variables were obtained from the institution colorectal cancer database and analyzed. RESULTS: Six patients underwent HAL APR from November 2004 to January 2006. Mean operative time was 213 min with no conversions or intraoperative complications. One patient developed post-operative ileus which resolved spontaneously. There were no other morbidities or mortalities. Mean hospitalization was 6.8 days. After a mean follow-up of 13.3 months, one patient developed a parastomal hernia which was subsequently repaired during liver resection for liver metastases. No other long-term complications occurred. CONCLUSION: HAL APR with the hand device placed at the planned stoma site is technically feasible. Without creating an additional incision, the operation is oncologically comparable and renders similar short-term outcomes as SL methods, maintaining the benefits of a minimally invasive approach.

Hand-assisted laparoscopic colectomy versus standard laparoscopic colectomy: a cost analysis.

OBJECTIVE: There is a relative dearth of literature comparing hand-assisted (HALC) to standard (SLC) laparoscopic colectomies. HALC seems beneficial in terms of shorter operative times and lower conversion rates, but this is counterbalanced by a greater inflammatory response, larger incisions and higher direct costs. Nevertheless, these results are not consistent throughout existing studies and there are to date no detailed cost comparisons. Our hypothesis was that HALC would not incur significantly higher institutional costs compared with standard laparoscopic techniques. METHOD: Patients undergoing either SLC or HALC between August 2004 and September 2006 were retrospectively reviewed. All patients were managed using a standard protocol. Outcomes assessed included operative times, conversion rates, pain scores, time to resolution of ileus, length of stay and complications. Total costs were calculated from the day of surgery. Statistical analyses included chi(2), Fisher's exact test, the Mann-Whitney U-test or nonparametric bootstrapping method. RESULTS: Seventy-three patients underwent SLC while 101 had HALC. Demographics and indications for surgery in both groups were similar; the majority were performed for colorectal cancers. Operative times were shorter (147.5 vs 172.5 min, P < 0.05) and complication rates lower (28.7%vs 45.2%, P < 0.025) for HALC. There was no significant difference in the other clinical outcomes. Operative costs and cost of consumables were higher for HALC (US$4024.2 vs US$3568.1, P = 0.01 and US$1724.7 vs US$1302.7, P < 0.001, respectively). However, total costs were not significantly different (HALC US$8999.8, SLC US$7910.7, P = 0.11). CONCLUSION: Institutional costs are not significantly higher for HALC compared with SLC.

An evaluation of the value of group education in recently diagnosed diabetes mellitus.

Diabetic patients have a 12% to 25% lifetime risk of developing foot complications leading to significant morbidity and mortality. The objective of this study was to assess the effectiveness of group education in improving patient awareness of foot care. The authors evaluated the effect of group size and areas in which knowledge seemed to be most affected. Patients attending a 2-hour teaching session between November 2005 and March 2006 were recruited. Patients filled in an 18-part questionnaire before and after the teaching session to assess knowledge. Fifty-nine patients recently diagnosed with diabetes mellitus or foot complications were recruited for 7 sessions. Analysis of the data showed a statistically significant improvement in foot care knowledge after the teaching session compared with before (69% to 85%, P < .001). Patients in the smaller group (n < 10) had significantly higher scores compared with the bigger groups (n > 10; P < .025). These data show the benefit of group education about foot care for patients with diabetes. Smaller groups benefited more than larger ones did, which could be attributed to the sizes allowing for better interaction between the tutor and patient. As patient knowledge is variable from individual to individual, smaller teaching sessions may allow patients to address specific concerns.

Randomized clinical trial of local bupivacaine perfusion versus parenteral morphine infusion for pain relief after laparotomy.

BACKGROUND: Opioids are often used to decrease pain following laparotomy but are associated with unwanted side-effects. The effectiveness of local perfusion of bupivacaine 0.5 per cent following laparotomy was studied. METHODS: A prospective randomized study involving patients undergoing laparotomy for major colorectal surgery using a left iliac fossa skin crease incision was undertaken. Patients were randomized to receive either intermittent intravenous morphine infusion on demand with patient-controlled analgesia (PCA group) or continuous wound perfusion of local bupivacaine 0.5 per cent for 60 h (LA group). RESULTS: Seventy patients were recruited, 35 in each group. Patient demographics, surgical and recovery variables and complications were comparable in the two groups. The wound lengths were similar (median 14 cm in both groups). There was no statistically significant difference in postoperative pain scores at rest and with movement between the two groups, except for pain scores at rest on the first postoperative day (P = 0.03). The median total amount of morphine used was significantly greater in the PCA group (median 38 versus 0 mg in the LA group; P < 0.001). CONCLUSION: Direct continuous local wound perfusion of bupivacaine 0.5 per cent is as effective as PCA for postoperative pain relief after laparotomy. It is a safe and feasible alternative to parenteral opioids.

Gastrointestinal manifestations of systemic lupus erythematosus.

Gastrointestinal symptoms are common in patients with systemic lupus erythematosus (SLE) and can be due to primary gastrointestinal disorders, complications of therapy or SLE itself. In this case report, we describe three different presentations and causes of gastrointestinal complaints in patients with SLE. Diagnostic and management problems are discussed.

Pseudomembranous colitis in a patient treated with paclitaxel for carcinoma of the breast: a case report.

INTRODUCTION: The concomitant antimicrobial properties of antineoplastic agents may play a role in causing pseudomembranous colitis, which has been documented for cisplatin, cyclophosphamide and 5-fluorouracil. CLINICAL PICTURE: We describe the first case reported in the English literature of severe pseudomembranous colitis occurring in a patient given paclitaxel as adjuvant chemotherapy for breast cancer. There was no prior antibiotic therapy. Stool culture confirmed Clostridium difficile. TREATMENT: Oral vancomycin, metronidazole and cholestyramine led to prompt improvement of intestinal symptoms, which resolved in two weeks. OUTCOME: Repeat colonoscopy performed 3 months later showed total resolution of the colitis. CONCLUSIONS: Awareness of pseudomembranous colitis after paclitaxel chemotherapy can avert life-threatening complications.

Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months.

PURPOSE: Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique. METHODS: A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique = 62; stapled hemorrhoidectomy = 57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs. RESULTS: Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9) vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4) vs. 2.6 (0.4); P < 0.005) at two weeks, and analgesic requirements were more for up to six weeks (P < 0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent) vs. 19 (33.3 percent); P < 0.05) and pruritus (27 (43.5 percent) vs. 9 (15.8 percent); P < 0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent) vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8) vs. 17.1 (1.9) days; P < 0.05), but the total costs incurred were less ($921.17 (16.85) vs. $1,283.09 (31.59); P < 0.005). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.

Antineutrophil cytoplasmic antibodies (ANCAs) in patients with inflammatory bowel disease show no correlation with proteinase 3, lactoferrin, myeloperoxidase, elastase, cathepsin G and lysozyme: a Singapore study.

INTRODUCTION: The pathogenic importance of antineutrophil cytoplasmic antibodies (ANCAs) in inflammatory bowel disease (IBD) is unclear and target antigen localisation studies may lend insight to the specific pathogenic mechanisms of IBD. In this pilot study, we looked at occurrence of ANCA in Asian IBD patients. In ANCA-positive samples, we analysed for the presence of target antigens i.e. proteinase 3, lactoferrin, myeloperoxidase, elastase, cathepsin G and lysozyme. MATERIALS AND METHODS: This prospective study was carried out from July 1997 to February 1998. Sera were screened for ANCAs with indirect immunofluorescent test and tested with an enzyme immunoassay (ELISA) kit which provides a semi-quantitative assay for human IgG autoantibodies against 6 antigens: proteinase 3, lactoferrin, myeloperoxidase, elastase, cathepsin G and lysozyme. RESULTS: A total of 75 patients were studied: 50 with IBD and 25 controls with functional bowel disease. Ten had Crohn's disease (CD) and 40 had ulcerative colitis (UC). There was no racial predilection among the Chinese, Malays or Indians. In CD, 1 was positive for cytoplasmic ANCA (cANCA) and 2 for perinuclear ANCA (pANCA). In UC, 4 were positive for pANCA, 15 for atypical perinuclear ANCA (apANCA) and 1 for cANCA. In the CD and UC population, the proportion positive for ANCA was 30% and 50%, respectively. There was no ANCA detected among the controls. Of those ANCA-positive IBD patients (n:23), only 1 demonstrated anti-myeloperoxidase antibodies. No antibodies were detected against the other 5 antigens tested. CONCLUSIONS: This pilot Singapore study concludes that there is no significant ANCA association with proteinase 3, lactoferrin, myeloperoxidase, elastase, cathepsin G and lysozyme.

Comparing treatment response and complications between podophyllin 0.5%/0.25% in ethanol vs podophyllin 25% in tincture benzoin for penile warts.

AIM: The aims of this study were to: 1) ascertain if podophyllin resin in 0.5% [PE(0.5%)] and 0.25% [PE(0.25%)] in ethanol (PE) self-applied sequentially for 3 days with 4 days break cycle is as effective as supervised podophyllin 25% in tincture benzoin (PB) applied in the clinic biweekly in treating penile warts and 2) ascertain if PE causes less skin irritation than PB. METHODS AND RESULTS: The clearance rate of penile warts was 36.4% (4/11) in PE (0.5%) treated group, 66.7% (4/6) in the PE (0.25%) treated group and 33.3% (6/18) for PB treated group after 1 week (ns). The wart clearance rate at 6 weeks for PE (0.5%) treated group, PE (0.25%) treated group and PB treated group were 81.8% (9/11), 100% (6/6) and 83.3% (15/17) respectively (ns). There were 47 individual warts on the penis of the 17 patients in the PE treated group and 58 individual warts on the penis of the 18 patients in the PB treated group. Based on the response of individual warts to the 2 treatment regimens, the clearance rate was 42.6% (20/47) for the PE treated group and 25% (15/56) for the PB treated group after 1 week treatment (ns). At 6 weeks follow-up, the clearance rate for the PE treated group and the PB treated group were 85.1% (40/47) and 73.2% (41/56) respectively (ns). Skin irritation including superficial erosions, pain and itch were observed in 47% (8/17) in patients treated with PE compared to 38.9% (7/18) in patients treated with PB (ns) during the 6 weeks follow-up period. The clearance rate of patients treated with PE (0.25%) was compared to those treated with PE (0.5%). Four out of six of PE (0.25%) treated patients had clearance of warts after 1 week and 100% clearance at the end of 6 weeks. None experienced any skin irritation. CONCLUSION: This study demonstrates that 0.5% podophyllin (and possibly 0.25% podophyllin) in ethanol is effective in eradicating penile warts. It can be used by patients for self-treatment at home with greater convenience and is more cost effective than the conventional podophyllin 25% in tincture benzoin paint.

Acute viral hepatitis E: clinical and serologic studies in Singapore.

Seroprevalence of hepatitis E is now documented in many countries around the world, but studies of its clinical manifestations and serologic course have been confined to endemic areas. We have prospectively evaluated the occurrence, evolution, and outcome of acute hepatitis E in our patients. Fifteen patients (11 men, 4 women; median age: 41 years) were diagnosed to have acute, sporadic hepatitis E between July 1993 and January 1995; 10 of the 15 were followed up. Sera anti-hepatitis E virus (HEV) immunoglobulin (Ig)G and IgM antibodies and HEV ribonucleic acid in the blood and stool were tested at weeks 1 and 2; serial tests for hepatitis E antibodies and liver function were carried out at months 1, 3, 6, 9, 12, and 18. Coinfection with hepatitis A and superinfection on chronic hepatitis B were found in 3 and 2 patients, respectively. One patient had transient passage of virus in the stool, but none was viremic. Eighty-seven percent of patients lost their IgM antibodies within 3 months, but anti-HEV IgG, once present, persisted throughout follow-up. All patients but one had complete recovery. A higher than reported level of alanine transaminase (mean: 28.5 times normal) and the lack of viremia during acute infection in our patients may be due to increased immune-mediated viral clearance.

Atrophie blanche--a special form of vasculopathy.

Although atrophie blanche is classified as a vasculitis, its presentation and management differ from the classical vasculitis. We present a patient with idiopathic atrophie blanche and discuss its management.

Cutaneous gangrene secondary to metastatic calcification in end stage renal failure--a case report.

Metastatic calcification is a frequent association of chronic renal failure but skin involvement is accepted as a rare, albeit well recognised, complication accompanying the secondary hyperparathyroidism that results from renal impairment, although the aetiology remains unknown. Skin involvement can take the form of metastatic calcinosis cutis or cutaneous gangrene resulting from vascular calcification. There have been reported cases which describe the healing of gangrenous areas following parathyroidectomy as well as use of dietary restriction of phosphorus and phosphate binding antacids(1-6). We report a case of a 35-year-old man with end stage renal failure who presented with cutaneous gangrene but who eventually succumbed despite a subtotal parathyroidectomy and review some of the literature concerning this subject.

Neurologic symptoms due to possible chromium deficiency in long-term parenteral nutrition that closely mimic metronidazole-induced syndromes.

BACKGROUND: We previously described a patient on home parenteral nutrition (HPN) who developed glucose intolerance and neuropathy that only responded to an infusion of chromium. A patient on HPN who had neuropathy and glucose intolerance was studied. He was also on metronidazole, which could have caused the neuropathy, but the symptoms and signs persisted. METHODS: Baseline clinical examination, nerve conduction studies, serum vitamin and trace element levels, and glucose tolerance were measured. Then, 250 micrograms of trivalent chromium as the chloride salt was infused daily for 2 weeks. The above studies were repeated. RESULTS: The patient at baseline had peripheral neuropathy of the axonal type and was glucose intolerant. Serum chromium was raised in this patient above the reference range. Despite raised serum levels, the infusion of chromium resulted in clinical remission that was marked 4 days after starting the infusion. Normalization of nerve conduction also occurred within 3 weeks of the initial study. CONCLUSIONS: Neuropathy and glucose intolerance may occur despite increased serum chromium levels and respond to chromium infusion. The previous use of drugs such as metronidazole should not exclude chromium as a potential treatment for neuropathy in HPN patients.

Harry M. Vars Research Award. Increase in lumbar spine bone mineral content in patients on long-term parenteral nutrition without vitamin D supplementation.

BACKGROUND: We had previously shown that short-term withdrawal of vitamin D in patients with metabolic bone disease complicating home parenteral nutrition (HPN) corrected osteomalacia. We therefore conducted a prospective study of the effect of long term withdrawal of vitamin D in patients on home parenteral nutrition. METHODS: Baseline measurements of bone mineral content, serum levels of calcium, phosphorus, parathormone, 25-OH and 1,25 (OH)2D; urinary calcium; and bone mineral density were measured. Then all parenteral vitamin D was withdrawn and the above parameters were followed for a mean of 4.5 years. RESULTS: Lumbar spine bone mineral content (LSBMC) was 0.79 +/- 0.06 g/cm2 at the start of the study, well below the reference value, 1.16 +/- 0.13 g/cm2. Parathyroid hormone (PTH) (0.48 +/- 0.24 pmol/L) and 1,25-(OH)2D levels (22.8 +/- 7.9 pmol/L) were low and 25-hydroxyvitaniin D levels were normal (33.3 +/- 5.5 nmol/L) before removing vitandn D from the HPN solutions. After withdrawal of vitamin D for 4.5 +/- 0.2 years LSBMC increased from 0.79 +/- 0.06 to 0.93 0.07 g/cm2 (p < 0.005). Calcium phosphorus, magnesium and 25-hydroxyvitamin D did not change significantly, 1,25(OH)2D, and PTH levels became normal after withdrawal of vitamin D. CONCLUSIONS: In selected patients with depressed PTH levels, long-term withdrawal of vitamin D during HPN increases LSBMC and levels of PTH and 1,25(OH)2D. There is no reduction of the mean level of 25-hydroxyvitamin D.

Common genital dermatoses in male patients attending a public sexually transmitted disease clinic in Singapore.

The male genitalia is a common site of various dermatoses. Male patients attending a sexually transmitted disease (STD) clinic may present with dermatoses that are not due to sexually transmitted diseases. A prospective study on 467 male patients attending a public STD clinic showed various dermatoses which were either anatomical variants (pearly penile papules in 67 patients [14.3%], sebaceous hyperplasia in 16 [3.4%], Tyson's glands in 32 [7%] and penile melanosis in 13 [2.8%]) or pathological conditions (balanitis in 45 [9.6%], eczema in 10 [2.1%], traumatic ulcers in 10 [2.1%], folliculitis and furunculosis in 8 [1.7%], scabietic nodules in 7 [1.5%], genital candidiasis in 7 [1.5%] and a few miscellaneous conditions). Fifty percent of the patients with Tyson's glands also had pearly penile papules. Most of the anatomical variants were incidental findings whereas most patients with the pathological dermatoses presented with these lesions. Unfamiliarity with these dermatoses may cause unnecessary anxiety to the patient and physician, resulting in inappropriate treatment.

Genital ulcer disease in patients attending a public sexually transmitted disease clinic in Singapore: an epidemiologic study.

Genital ulcer disease forms about 10% of all sexually transmitted diseases (STDs) in Singapore. In this retrospective study of 531 cases of genital ulcer disease presenting at the Department of STD Control, 91.6% were due to venereal causes and 8.4% were due to non-venereal causes. The venereal causes of genital ulcers were found to be genital herpes (71.5%), chancroid (15.8%), primary syphilis (3.4%) and lymphogranuloma venereum (1%). The non-venereal causes were mainly trauma, drug eruptions or were non-specific in nature. The peak incidence in both sexes occurred in the 20-39 year age group. Males outnumbered females by a ratio of 5.8:1. The ethnic distribution showed an under-representation of Malays relative to the racial makeup of the general population, reflecting perhaps a protective effect conferred by circumcision from genital ulcer diseases or a lower health-risk sexual behaviour in this ethnic group. The accuracy of initial clinical diagnosis was low indicating the need for laboratory investigations to establish accurate aetiologic diagnosis. Commercial sex workers were the main source of infection in males, highlighting the continued need to educate, screen and effectively treat this high risk group.

Developments in the antiviral treatment of genital herpes.

There have been impressive advances made over the last decade in the management of sexually transmitted viral diseases, especially in the development of effective antiviral agents. Acyclovir, first synthesized in 1974, has proved to be an effective and safe drug for the treatment of primary and frequently recurring genital herpes, according to the various medical publications over the last 10 years. This article reviews the use of acyclovir in the treatment of genital herpes and discusses the potential problem of acyclovir resistance. It also discusses two newer antiherpes drugs, famciclovir and valaciclovir, and the preliminary results of studies on their efficacy in the treatment of genital herpes.

A comparative study of calcipotriol ointment and tar in chronic plaque psoriasis.

The antipsoriatic efficacy, tolerability and safety of calcipotriol ointment was compared with tar in a prospective, right/left randomized, investigator-blinded controlled study. Calcipotriol ointment 50 micrograms/g twice daily was applied to one-half of the body. On the opposite side, white soft paraffin was applied in the morning, and coal tar solution BP 15% v/w in aqueous cream in the evening. Thirty patients with stable chronic plaque-type psoriasis were recruited. Assessments were made at 2, 4 and 6 weeks. Three patients were withdrawn from the study. A decrease in PASI score was seen on both sides at 2, 4 and 6 weeks. The differences from baseline between the two treatments were statistically significant in favour of calcipotriol. Improvement with calcipotriol was rapid in the first 2 weeks of treatment. With tar, significant improvement occurred only after 4 weeks of treatment. The differences in the scores for erythema, induration and desquamation from baseline between the two treatments were also statistically significantly in favour of calcipotriol at all evaluation points. Seven patients developed irritation on the calcipotriol-treated side, but there were no adverse effects on the tar-treated side. In two patients, itching associated with psoriasis was reduced by the calcipotriol. Although the mean serum calcium and phosphate levels remained within the normal ranges after 6 weeks' treatment, there were significant changes in their values compared with baseline.