An experimental ointment formulation of pimecrolimus is effective in psoriasis without occlusion

Update of calcineurin inhibitors to treat inverse psoriasis: A systematic review

Inverse psoriasis commonly involves skin fold areas including the axillae, perianal skin, intergluteal cleft, inframammary, genital/inguinal, abdominal, and retroauricular folds. Topical calcineurin inhibitors are indicated for the treatment of atopic dermatitis but have also been studied in the treatment of psoriasis. The object of the present study is to define the efficacy of topical calcineurin inhibitors in the treatment of psoriasis. We checked for English-vernacular articles conveyed since 1990 in PubMed, Ovid/Cochrane, and Embase using "tacrolimus," "pimecrolimus," or "topical calcineurin inhibitors," and "psoriasis" as keywords. Eight double-blind studies and seven open studies displayed the ampleness of topical tacrolimus in psoriasis. Included studies demonstrated a considerable efficacy of topical administration of tacrolimus and pimecrolimus in the treatment of psoriasis, especially for facial, genital, and intertriginous areas. The role of topical tacrolimus and pimecrolimus in the treatment of psoriasis seems to be promising as shown by the results of double-blind and open studies. Because these agents do not cause cutaneous atrophy, they have a special role in facial, genital, and intertriginous psoriatic lesions. Both agents await additional investigation to determine their roles.

Psoriasis treatment: Unconventional and non-standard modalities in the era of biologics

Psoriasis is a potentially debilitating inflammatory dermatosis affecting 0.2%-4.8% of the population worldwide causing a significant occupational, personal or psychosocial morbidity to these patients for life. The basic aim of psoriasis therapy is to control the disease to maximum possible extent and improve the patient’s quality of life. Management of triggers for flare-ups, lifestyle modifications, and dietary supplements are often recommended. Intermittent or rotational therapy with frequent alterations in treatment options is usually needed to reduce toxicity of anti-psoriatic drugs in the absence of safer alternatives. Currently, several biological agents categorized as either T-cell targeted (e.g., Alefacept, Efalizumab) or cytokine modulating (e.g., Adalimumab, Infliximab, Etanercept) are available for treating severe psoriasis. However, their high cost is often precluding for most patients. The usefulness of systemic (methotrexate, cyclosporine, acitretin or several other therapeutic agents) or topical (tar, anthralin, corticosteroids or calcipotriol ointments, phototherapy with or without psoralens) therapies has been well established for the management of psoriasis. The literature is also replete with benefits of less used non-standard and unconventional treatment modalities (hydroxycarbamide, azathioprine, leflunomide, mycophenolate mofetil, isotretinoin, fumarates, topical calcineurin inhibitors, peroxisome proliferator-activated receptors agonists, statins, sulfasalazine, pentoxifylline, colchicine, grenz ray therapy, excimer laser, climatotherapy and balneophototherapy, peritoneal dialysis, tonsillectomy, ichthyotherapy, etc.). These can be used alternatively to treat psoriasis patients who have mild/minimal lesions, are intolerant to conventional drugs, have developed side effects or achieved recommended cumulative dose, where comorbidities pose unusual therapeutic challenges, or may be as intermittent, rotational or combination treatment alternatives.

Macrolactam Immunomodulators (Tacrolimus and Pimecrolimus): New Horizons in the Topical Treatment of Inflammatory Skin Diseases

Tacrolimus and pimecrolimus are new macrolactam immunomodulators which were developed for the treatment of inflammatory skin diseases, mainly atopic dermatitis. In this article, we review the pharmacologic properties of the drugs, their side effects, and their clinical uses.

Efficacy of topical calcineurin inhibitors in psoriasis

BACKGROUND

Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are indicated for the treatment of atopic dermatitis but have also been studied in the treatment of psoriasis.

OBJECTIVE

To define the efficacy of topical calcineurin inhibitors in the treatment of psoriasis.

METHODS

We searched for English-language articles published since 1990 in PubMed, Ovid/Cochrane, and Embase using "tacrolimus," "pimecrolimus," or "topical calcineurin inhibitors" and "psoriasis."

RESULTS

Nine double-blind and 13 open studies demonstrated the efficacy of topical tacrolimus in psoriasis, especially for facial, genital, and intertrigious psoriasis, and four double-blind and one open study demonstrated the efficacy of topical pimecrolimus.

CONCLUSIONS

The evidence (double-blind and open studies) is strong that topical tacrolimus and, to a lesser extent, pimecrolimus have efficacy in the treatment of psoriasis. Since these agents do not cause cutaneous atrophy, they likely have a special role in facial, genital, and intertriginous psoriasis. Further studies would help define their roles in psoriasis.

Nanostructured lipid carrier-loaded hyaluronic acid microneedles for controlled dermal delivery of a lipophilic molecule

Nanostructured lipid carriers (NLCs) were employed to formulate a lipophilic drug into hydrophilic polymeric microneedles (MNs). Hyaluronic acid (HA) was selected as a hydrophilic and bioerodible polymer to fabricate MNs, and nile red (NR) was used as a model lipophilic molecule. NR-loaded NLCs were consolidated into the HA-based MNs to prepare NLC-loaded MNs (NLC-MNs). A dispersion of NLCs was prepared by high-pressure homogenization after dissolving NR in Labrafil and mixing with melted Compritol, resulting in 268 nm NLCs with a polydispersity index of 0.273. The NLC dispersion showed a controlled release of NR over 24 hours, following Hixson-Crowell's cube root law. After mixing the NLC dispersion with the HA solution, the drawing lithography method was used to fabricate NLC-MNs. The length, base diameter, and tip diameter of the NLC-MNs were approximately 350, 380, and 30 μm, respectively. Fluorescence microscopic imaging of the NLC-MNs helped confirm that the NR-loaded NLCs were distributed evenly throughout the MNs. In a skin permeation study performed using a Franz diffusion cell with minipig dorsal skin, approximately 70% of NR was localized in the skin after 24-hour application of NLC-MNs. Confocal laser scanning microscopy (z-series) of the skin at different depths showed strong fluorescence intensity in the epidermal layer, which appeared to spread out radially with the passage of time. This study indicated that incorporation of drug-loaded NLCs into MNs could represent a promising strategy for controlled dermal delivery of lipophilic drugs.

S3 - Guidelines on the treatment of psoriasis vulgaris (English version). Update

Psoriasis vulgaris is a common and often chronic inflammatory skin disease. The incidence of psoriasis in Western industrialized countries ranges from 1.5% to 2%. Patients afflicted with severe psoriasis vulgaris may experience a significant reduction in quality of life. Despite the large variety of treatment options available, surveys have shown that patients still do not received optimal treatments. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologi sche Gesellschaft (DDG) and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. They were first published in 2006 and updated in 2011. The Guidelines focus on induction therapy in cases of mild, moderate and severe plaque-type psoriasis in adults including systemic therapy, UV therapy and topical therapies. The therapeutic recommendations were developed based on the results of a systematic literature search and were finalized during a consensus meeting using structured consensus methods (nominal group process).

Innovative use of topical calcineurin inhibitors

Topical tacrolimus and pimecrolimus are indicated for treatment of atopic dermatitis, but they have been studied in many off-label uses. Double-blind and open studies have shown favorable results with topical tacrolimus and pimecrolimus in oral lichen planus. In 1 study of oral lichen planus, blood tacrolimus was detected in 54% of patients, but there were no signs of systemic toxicity. Double-blind and open studies of vitiligo have shown favorable results with tacrolimus in combination with excimer laser, especially for lesions over bony prominences and on extremities. Similarly, double-blind studies of vitiligo have shown favorable results when pimecrolimus is combined with narrow-band UVB, especially for facial lesions. Double-blind and open studies of psoriasis have shown favorable results for tacrolimus and pimecrolimus, especially for inverse psoriasis. Topical calcineurin inhibitors have been effective in many other cutaneous disorders, and further studies would help clarify their roles.

Use of pimecrolimus cream in disorders other than atopic dermatitis

BACKGROUND

Pimecrolimus is indicated for treatment of atopic dermatitis and has been evaluated in many other disorders.

OBJECTIVE

To review the efficacy of pimecrolimus in treatment of disorders other than atopic dermatitis.

METHODS

We performed a PubMed search of the English-language literature using the key word "pimecrolimus." We reviewed articles reporting the use of pimecrolimus in disorders other than atopic dermatitis and classified them by the type of study used to evaluate efficacy.

RESULTS

Randomized, double-blind studies have shown that pimecrolimus is superior to vehicle in treatment of seborrheic dermatitis, hand dermatitis, and asteatotic eczema but have yielded conflicting results regarding intertriginous psoriasis and vitiligo. Open-label studies involving four or more patients have shown favorable results in many disorders, including contact dermatitis, rosacea, lichen sclerosus, and oral and genital lichen planus. Case reports have shown that topical pimecrolimus may be useful in cutaneous graft-versus-host disease, lichen striatus, cutaneous lichen planus, and many other disorders.

CONCLUSIONS

Topical pimecrolimus appears to be an effective treatment for many disorders other than atopic dermatitis, especially seborrheic dermatitis, hand dermatitis, and asteatoic eczema. It may be effective in many other disorders, but its role in these disorders remains to be clarified by additional studies.

Pimecrolimus 1% cream in the treatment of facial psoriasis: a 16-week open-label study

BACKGROUND

Facial psoriasis requires a treatment approach other than topical corticosteroids which bear the risk of skin atrophy. Topical pimecrolimus has been shown to be effective in atopic eczema and recently in psoriasis.

OBJECTIVE

The aim of this open-label single-center investigator-initiated study was to evaluate the efficacy and safety of pimecrolimus 1% cream in patients with facial psoriasis.

METHODS

20 adults with facial psoriasis were enrolled. Pimecrolimus 1% cream was applied twice daily to psoriatic lesions of the face over an 8-week period. An 8-week follow-up was added.

RESULTS

All clinical parameters showed a significant improvement after 8 and 16 weeks compared to baseline. Pimecrolimus 1% cream was effective and well tolerated.

CONCLUSIONS

This is the first clinical study with a larger patient cohort reporting a relevant therapeutic effect and favorable safety profile of pimecrolimus 1% cream in facial psoriasis.

Psoriasis: consensus on topical therapies

OBJECTIVE

A consensus conference was convened to evaluate the topical treatment of psoriasis.

PARTICIPANTS

Members of the International Psoriasis Council (IPC) with broad clinical experience in the treatment of psoriasis and a specialist in meta- and pharmacoeconomic analyses were invited to participate on the consensus panel. Those accepting the invitation convened in Saariselkä, Finland.

EVIDENCE

An advisory group on topical treatments was nominated by the organizing panel members. All participants reported at the consensus conference on evidence based data with respect to disease severity assessment, the available data on efficacy and safety and on a comparative efficacy/safety analysis.

CONSENSUS PROCESS

At the consensus conference, the presentations were discussed and conclusions, which were reached by the group, were recorded. Active participants of the group wrote assigned sections of this consensus document with a majority of participants agreed on the conclusions.

Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris

Psoriasis vulgaris is a common and often chronic inflammatory skin disease. The incidence of psoriasis in Western industrialized countries ranges from 1 to 2%. Patients afflicted with severe psoriasis vulgaris may experience a significant reduction in quality of life. Despite the large variety of treatment options available, patient surveys have revealed lack of satisfaction with the efficacy of available treatments and a high rate of non-compliance. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft (DDG) and the Berufsverband Deutscher Dermatologen (BVDD) initiated a project to develop evidence-based guidelines for the management of psoriasis. These resulting Guidelines focus on induction therapy in cases of mild, moderate, and severe plaquetype psoriasis in adults. The Guidelines include evidence-based evaluation of the efficacy of all currently available therapeutic options in Germany. In addition, they offer detailed information on how best to administer the various treatments and give information on contraindications, adverse drug reactions, and drug interactions as well as estimates of practicability and cost. The Guidelines were developed following the recommendations of the Arbeitsgemeinschaft wissenschaftlicher medizinischer Fachgesellschaften (AWMF). The therapeutic recommendations were developed by an expert group and finalized during interdisciplinary consensus conferences.

Netherton syndrome: Successful use of topical tacrolimus and pimecrolimus in four siblings

Netherton's syndrome (NS) is a rare autosomal recessive disease comprised of ichthyosis in the form of ichthyosis linearis circumflexa, hair shaft defects and atopic manifestations with an elevated IgE level. Various therapeutic options have been used in NS with variable success. Tacrolimus and pimecrolimus belong to the family of calcineurin inhibitors. They bind cytoplasmic proteins and the resulting complex binds calcineurin, inhibiting its ability to dephosphorylate the nuclear factor of activated T cells, thus suppressing gene transcription. There have been conflicting reports of the usefulness of tacrolimus in NS patients, with systemic absorption being the main adverse outcome. Here we report four Saudi siblings (two boys and two girls) with NS who were treated with topical tacrolimus and pimecrolimus with good control of their skin disease without any toxic effect. To our knowledge, this is the second report of the use of topical pimecrolimus in NS in the English literature.

Emerging drugs for psoriasis

Psoriasis is a chronic immune-mediated inflammatory skin disease characterised by abnormal keratinocyte differentiation and proliferation. The immunopathogenesis is complex and novel evidence shows the involvement of both innate and adaptive immune response. Type 1 T cells and their effector cytokines play a pivotal role. Several drugs under preclinical and clinical development for psoriasis are directed against the immune response, targeting activation or proliferation of T cells, their trafficking and skin-homing, or effector cytokines. Among these, great attention has been given to TNF-alpha, following the demonstration of effectiveness of anti-TNF-alpha biologicals, and to IFN-gamma inducers. Another appealing approach concerns drugs capable of inducing immunological tolerance. Progress made in the recognition of intracellular events has prompted the development of small molecules and oligonucleotides that can inhibit specific molecular targets. There is, however, a plethora of other emerging drugs, clearly suggestive of the current interest for psoriasis, which are briefly described in this paper.

Calcineurininhibitoren zur topischen Therapie der Psoriasis

There are numerous possibilities for specific antiinflammatory therapy of psoriasis. One option is the use of calcineurin inhibitors. To date, only systemic administration of cyclosporine A is approved for this indication. Nonetheless cyclosporine A, tacrolimus and pimecrolimus can all be classed as effective anti-inflammatory agents for the therapy of psoriasis. Unfortunately, the vehicles currently available do not insure adequate topical delivery of these substances. Clinical efficacy of the preparations can be proven only when additional penetration-promoting measures are used or penetration-facilitating conditions exist. The entire group can be expected to play a greater role in the topical therapy of psoriasis if advances in vehicles and delivery systems are made.

Role of topical therapies in the management of cutaneous disease

Within the last decade, healthcare providers have had a larger selection of effective novel topical immunomodulatory agents to treat many dermatologic conditions. Novel mechanisms of action of newer topical agents have facilitated differentiation from well-established topical agents such as corticosteroids and 5-fluorouracil. Further, because of a growing understanding of the immune mechanisms within the skin, the opportunity has arisen to use the body's immune system to effectively treat many dermatologic conditions, such as condyloma acuminata, actinic keratosis, basal cell carcinoma, and atopic dermatitis, while maintaining a favorable safety profile. Imiquimod 5% cream, an immune response modifier, is safe and effective in the treatment of condyloma acuminata, actinic keratosis, and primary superficial basal cell carcinoma (sBCC). Pimecrolimus cream 1% and tacrolimus ointment (0.1% and 0.03%) are safe and effective in the treatment of atopic dermatitis. This review highlights newer data on approved and investigational indications for these topical immunomodulatory agents.

Pimecrolimus in dermatology: atopic dermatitis and beyond

Pimecrolimus is a calcineurin inhibitor developed for the topical therapy of inflammatory skin diseases, particularly atopic dermatitis (AD). Pimecrolimus selectively targets T cells and mast cells. Pimecrolimus inhibits T-cell proliferation, as well as production and release of interleukin-2 (IL-2), IL-4, interferon-gamma and tumour necrosis factor-alpha. Moreover, pimecrolimus inhibits mast cell degranulation. In contrast to tacrolimus, pimecrolimus has no effects on the differentiation, maturation and functions of dendritic cells. In contrast to corticosteroids, pimecrolimus does not affect endothelial cells and fibroblasts and does not induce skin atrophy. Given the low capacity of pimecrolimus to permeate through the skin, it has a very low risk of systemic exposure and subsequent systemic side-effects. In different randomised controlled trials, topical pimecrolimus as cream 1% (Elidel) has been shown to be effective, well tolerated and safe in both adults and children with mild to moderate AD. In addition, pimecrolimus has been successfully used in inflammatory skin diseases other than AD, including seborrheic dermatitis, intertriginous psoriasis, lichen planus and cutaneous lupus erythematosus.

Psoriasis treatment: current and emerging directed therapies

Quality of life studies in patients with cutaneous psoriasis attest to its significant impact on day to day activities and personal social interactions. Up to 40% of patients with psoriasis may develop psoriatic arthritis, usually within 5-10 years after onset of the cutaneous disease, heightening quality of life issues. These data have prompted an increased awareness and interest in more aggressive management of psoriasis; coupled with a better understanding of immunopathogenesis, this has led to the development of new agents targeting specific cells and molecules involved in the development and maintenance of psoriatic plaques. Although non-biological therapies, including methotrexate and ciclosporin, show significant efficacy their side effect profiles have precluded their long term use for moderate to severe psoriasis. This review concentrates on new biological agents, focusing on the three agents approved for psoriasis within the past 18 months (alefacept, efalizumab, and etanercept). Phase II and III trial data on other agents in development (adalimumab and infliximab) are also presented. Surveys show many patients want to be treated more aggressively. It is hoped that the introduction of new agents that are more targeted and that hold the promise of fewer side effects will cause patients and their physicians to reconsider systemic treatment and, as a consequence, stimulate other patients to reconsider treatment for psoriasis. Close cooperation between dermatologists and rheumatologists, particularly in the area of psoriatic joint disease, will enhance these considerations.

Novel pharmacological approaches in the treatment of psoriasis

Progress in the understanding of psoriasis as a T-cell mediated inflammatory disease has led to the development of new immunomodulatory therapies. Currently the main focus is on the so-called biologics (or biological agents), including fusion proteins, monoclonal antibodies, cytokines and selective receptors. They mainly target single steps in the complex cascade of humoral and cellular inflammatory immuno-mechanisms that finally lead to the accelerated growth of epidermal and vascular cells in the psoriatic lesions. The most promising and advanced biological agents are discussed along with their influence on the critical pathophysiological steps in psoriasis, including depletion of T cells, blockade of initial T-cell activation and T-cell receptor (TCR) stimulation, blockade of costimulatory signals and T-cell proliferative signals as well as restoration of the T helper type 1 (Th1)/Th2 balance by diminishing type 1 cytokines and administration of type 2 cytokines. In addition to the biological agents, further development of 'classical' dermatological therapies, such as retinoids, or the discovery of new indications for non-dermatological agents contribute to the novel pharmacological approaches in the treatment of psoriasis.