There are various clinical types of psoriasis, such as plaque psoriasis, guttate psoriasis, generalized psoriasis progressing to erythrodermia. Psoriasis affect various parts of the body including extremities, lumbar area, head , nails , skin folds , palms and soles , genitalia.
Palmo-planatar psoriasis is a peculiar clinical subtype of the disease affecting palms and soles. The lesions found in this region could be typical erythemato-squamous plaques, hyperkeratosis, pustules. Nowadays psoriasis is considered as a heterogeneous disease and many authors define palmo-plantar pustulosis as a separate clinical entity with its genetic predisposition, course and therapeutic management which differ from psoriasis itself.
Palmo-planatar psoriasis could be hardly differentiated from chronic tylotic eczema both clinically and histologically, particularly when psoriasis does not affect the typical skin regions such as elbows, knees, hair, nails.
Materials and methods
Our object is to investigate the efficacy of combination of topical calcipotriol with local UVA radiation. To our knowledge there are no reports in the literature concerning this modality.
We present 43 patients which are divided into two groups according to the applied treatment modality. The characteristics of the patients from the two groups are as follows (Table 1):
Patients from group A were treated as follows: Calcipotriol ointment in the morning, applied on the affected areas at least 2,5 hours before UV-A radiation; 15 sessions of UV-A radiation (365 nm), applied only on the affected areas; emollients and keratolytics as adjuvant therapy.
Patients from group B were treated as follows: 5-methoxypsoralen (Meladinin®) - 0,30% solution, applied on the affected areas one hour before UV-A radiation; 15 sessions of UV-A radiation (365 nm), applied only on the affected areas; emollients and keratolytics as adjuvant therapy.
Skin biopsy was taken in 20 of the patients from group A: in 10 of them the histopathology showed characteristics for palmo-plantar psoriasis, in 7 of them the histopathological picture showed characteristics more likely for chronic dermatitis, while in three of them the histopathological diagnosis was palmo-plantar pustulosis.
Skin biopsy was taken in 9 of the patients from grpup B: in 6 of them the histolpathology showed characteristics for palmo-plantar psoriasis, in one of them the histopathological picture showed characteristics more likely for chronic dermatitis, while in two of them the histopathological diagnosis was palmo-plantar pustulosis.
Evaluation
The evaluation of the therapeutic effect in the two groups was done according to the Physician's Global Assessment (PGA) after the 15th UV-A radiation, including the following criteria:
Remission-no erythema and desquamation; residual discoloration may be present;
Marked improvement - mild erythema; no desquamation; no infiltration; hypo or hyper pigmented lesions;
Improvement - mild erythema, infiltration and desquamation; hypo or hyper pigmented lesions;
No change - status idem
Exacerbation- make new lesions
The results in the two groups are presented in the following table(2):
therapeutic effect, evaluated by the Physician's Global Assessment.
The obtained therapeutic results were statistically, analyzed. Our hypothesis, that there is no significant
difference in the therapeutic effect achieved in the two groups, was checked using
Chi (y)-square test. The statistical analyses of the results show that the effect of both therapeutic modalities are comparable.
Discussion
Palmo-planatar psoriasis is a peculiar clinical subtype of the disease affecting palms and soles. The lesions found in this region could be typical erythemato-squamous plaques, hyperkeratosis, pustules. Nowadays psoriasis is considered as a heterogeneous disease and many authors define palmo-plantar pustulosis as a separate clinical entity with its genetic predisposition, course and therapeutic management which differ from psoriasis itself.
Palmo-planatar psoriasis could be hardly differentiated from chronic tylotic eczema both clinically and histologically, particularly when psoriasis does not affect the typical skin regions such as elbows, knees, hair, nails.
Palmo-plantar psoriasis is a chronic disease which commonly is characterized with frequent exacerbations, difficulties in its management and resistance to therapy. Topical corticosteroids and phototherapy are most widely used therapeutic modalities for this subtype of psoriasis.
In cases when palmo-plantar psoriasis could hardly be differentiated clinically from chronic eczema even systemic corticosteroids are used, which is harmful for the course of psoriasis with severe exacerbations and complications of the disease after withdrawal of these drugs - erythrodermia and generalized pustulosis could develop. Therefore a therapeutic modality is needed which
should be effective in the disease management on one hand, and to be a steroid-free one on the other hand, thus avoiding steroid tachyphylaxis, the "rebound effect" of their use, and the development of their potential long-term side effects.
Phototherapy is a conventional steroid-free therapeutic option for palmo-plantar psoriasis. In cases of psoriasis localized on the palms and soles the topical PUVA is commonly used. This therapy includes photosensibilisation of the treated areas with 0,30% solution of meladinin (5-methoxypsoralen) and localized UV-A radiation by specific equipment for that purpose. The UV-A radiation is conducted one hour after the application of the photo sensitizer.
In Bulgaria the topical formulation of the photo sensitizers used for PUVA are not registered and the patients could not benefit from this therapeutic modality. This problem together with the data from the literature concerning the combination of phototherapy with topical agents for psoriasis made us turn to other therapeutic modalities for treatment of palmo-plantar psoriasis. Thus the idea of combining calcipotriol with UV-A emerged.
Data from the literature show that adding calcipotriol ointment to topical PUVA markedly improves the therapeutic response to phototherapy and the number of "responders" increases . Also such a combination allows decrease of the cumulative dose of phototherapy and the number of procedures of UV-A radiation (Scott LJ, et al. Am J Clin Dermatol 2001).
In the same time topical corticosteroids in combination with PUVA lead to decrease the dose of UV radiation, but not the number of sessions needed to achieve remissions. Exacerbations after such therapy are common ( Speight EL, et al. Br.J Dermatol 1994 ).
There are no data in the literature reporting such a modality combining calcipotriol and UV-A radiation without psoralen. Thus the presented study is unique. The obtained results show that there is no statistically significant difference between the two treatment groups in regard to the therapeutic effect.
This warrants us to conclude that combination of topical calcipotriol and local UVA radiation is an optional corticosteroid-free therapeutic modality for palmo-plantar psoriasis and it has a comparable effectiveness with PUVA. |
