Sequential topical therapy with clobetasol propionate spray followed by calcitriol ointment has joined the ranks of therapies that can boast documented safety and efficacy for moderate to severe plaque psoriasis.
The treatment strategy here is to wallop the disease initially with the super-high-potency corticosteroid to quickly quell an emerging flare, then turn to the safer, slower-acting metabolically active topical vitamin D to reduce the frequency of recurrent flare-ups.
This strategy proved effective and was well tolerated in a recent open-label multicenter study involving 170 patients. They received clobetasol propionate 0.05% spray (Clobex) twice daily for 4 weeks, then calcitriol 3 mcg/g (Vectical) twice daily for the next 8 weeks.
Eighty percent of patients were rated clear, almost clear, or mild at week 2, as were 93% at week 4, 92% at week 8, and 74% at week 12. Treatment success, defined as at least a one grade improvement in a five-point overall disease severity score at week 12, was accomplished in 84% of subjects. Body surface area involvement decreased significantly from 7.1% at baseline to 3.9% at week 12.
Dr. James Q. Del Rosso
Side effects consisted mainly of mild telangiectasias and stinging and burning. Less than 1% of subjects had signs of skin atrophy.
This sequential regimen is attractive because patients only have to remember to take one drug at a time, and also because topical vitamin D and its analogs are at present the only available agents targeting the abnormal keratinocyte differentiation that's a core feature of psoriasis, Dr. James Q. Del Rosso noted at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.
"Abnormal differentiation of keratinocytes is the one place where we have only one therapy. You really have to decide if that's important enough to you that you think it needs to be built into your treatment of psoriasis pretty much all of the time. You have to decide that for yourself," said Dr. Del Rosso of the University of Nevada, Las Vegas.
Dr. Del Rosso is a consultant to a number of pharmaceutical companies, including Galderma Laboratories, which funded the recently published open-label study (J. Drugs Dermatol. 2011;10:158-64).
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