Topical calcipotriol ointment in the treatment of morphea

The efficacy and safety of topical rapamycin-calcitriol for facial angiofibromas in patients with tuberous sclerosis complex: a prospective, double-blind, randomized clinical trial

BACKGROUND

The efficacy of topical rapamycin is well documented for tuberous sclerosis complex (TSC)-related facial angiofibromas (FAs). Calcitriol has been shown to lessen skin fibrosis and may be therapeutically beneficial to FAs.

OBJECTIVES

To evaluate whether topical rapamycin-calcitriol combination is an effective and safe treatment for TSC-related FAs.

METHODS

Fifty-two patients with TSC with FAs were enrolled in this prospective study including three 12-week periods. In period 1, either topical rapamycin 0·1% or calcitriol 0·0003% single-agent therapy vs. their combination was applied in a double-blind, left-right-randomized, split-face comparison. The primary outcome was the reduction of modified Facial Angiofibroma Severity Index (mFASI) at week 12. In period 2, the patients were reassigned to use on both cheeks the ointment that resulted in the better primary outcome in period 1. The treatment was discontinued in period 3 (week 25-36) and a follow-up mFASI was scored to evaluate the degree of recurrence.

RESULTS

The mean changes in mFASI at week 12 compared with baseline were -0·92, -0·44 and -1·09 for rapamycin (P ≤ 0·001), calcitriol (P = 0·039) and rapamycin-calcitriol combination (P ≤ 0·001), respectively. Although rapamycin-calcitriol combination and rapamycin had similar statistically significant decreases of mFASI at week 12, rapamycin-calcitriol combination resulted in faster improvement in erythema, greater reduction of papule elevation and longer durability after discontinuing treatment than rapamycin alone. The treatments were well tolerated.

CONCLUSIONS

This randomized clinical trial demonstrates that topical rapamycin-calcitriol combination therapy is an effective and safe regimen for TSC-related FAs. What is already known about this topic? Facial angiofibromas (FAs) cause substantial psychological distress in individuals with tuberous sclerosis complex (TSC), but invasive procedural treatments are not applicable to all patients. Topical rapamycin has been demonstrated as an effective and safe treatment regimen for TSC-related FAs. What does this study add? Compared with baseline (day 0), both topical rapamycin 0·1% and rapamycin 0·1%-calcitriol 0·0003% combination ointment achieved statistically significant reductions in modified Facial Angiofibroma Severity Index at week 12. Compared with rapamycin alone, extended use of the rapamycin-calcitriol combination regimen until week 24 showed more effectiveness in decreasing papule elevation and could maintain a longer therapeutic effect after treatment discontinuation. Linked Comment: Lee. Br J Dermatol 2020; 183:604-606.

A vitamin D analog inhibits Th2 cytokine- and TGFβ -induced periostin production in fibroblasts: a potential role for vitamin D in skin sclerosis

Scleroderma is an autoimmune disease characterized by extracellular matrix deposition and inflammation. Topical vitamin D analogs have been reported as effective treatments for scleroderma. We previously reported that a matricellular protein, periostin (POSTN), contributes to pathogenesis of scleroderma as POSTN knockout mice were resistant to bleomycin (BLM)-induced scleroderma. We investigated whether a vitamin D analog affects the expression of POSTN in dermal fibroblasts and in a BLM-induced scleroderma model. The vitamin D analog, maxacalcitol (22-oxacalcitriol [OCT]), was applied to dermal fibroblasts and POSTN expression was measured. The effect of OCT on Th2 cytokine- and TGFβ-induced POTSN and Collagen 1 α 1 (Col1A1) expression was also assessed. In vivo, OCT was administered to BLM-induced scleroderma model and outcomes were determined by dermal thickness, collagen density and POSTN expression. Treatment with OCT significantly decreased POSTN expression in dermal fibroblasts. Th2 cytokine- and TGFβ-induced expression of POSTN and Col1A1 was also suppressed by OCT. In vivo, OCT administration decreased the density of collagen bundles and POSTN expression in a BLM-induced scleroderma model. In addition to the previously reported immunosuppressive effect, the vitamin D analog OCT might be effective to treat scleroderma, in part through inhibition of Th2 cytokine- and TGFβ-induced POSTN expression.

Off-label uses of topical vitamin D in dermatology: a systematic review

BACKGROUND

Topical vitamin D is approved by the US Food and Drug Administration for the treatment of psoriasis but is also used off-label in the treatment of a variety of cutaneous diseases despite a lack of evidence-based guidelines.

OBJECTIVE

The objective of this study was to provide evidence-based clinical guidelines for the off-label use of topical vitamin D in the treatment of dermatologic disease.

METHODS

A systematic literature review was conducted via the MEDLINE, Embase, and CENTRAL databases for off-label uses of topical vitamin D analogues in the treatment of dermatologic disease other than psoriasis. The data were synthesized, and evidence-based recommendations were rendered according to the highest level of evidence available.

RESULTS

A total of 165 articles met the inclusion criteria. A moderate to strong recommendation was given for the use of topical vitamin D in combination with corticosteroids and phototherapy in vitiligo and as monotherapy for various ichthyoses, morphea, pityriasis alba, prurigo nodularis, and polymorphous light eruption. There is evidence showing that topical vitamin D is ineffective in the treatment of actinic keratosis, seborrheic keratosis, lichen planus, seborrheic dermatitis, alopecia areata, chemotherapy-induced alopecia, and hypertrophic scars.

CONCLUSION

Topical vitamin D analogues have an important role in the off-label treatment of dermatologic disease, but higher quality studies are still required.

Pediatric morphea

This article outlines the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment of childhood morphea. Also known as localized scleroderma, morphea is a fibrosing disorder of the skin and subcutaneous tissues. Morphea is differentiated from systemic sclerosis (scleroderma) based on the absence of sclerodactyly, Raynaud phenomenon, and nail-fold capillary changes. Confusion may occur because patients with morphea often have systemic symptoms such as malaise, fatigue, arthralgias, myalgias, and positive autoantibodies. Unlike morphea, systemic sclerosis has organ involvement, particularly gastrointestinal, pulmonary, and renal.

Post-Irradiation Morphea: Case report and review of the literature

BACKGROUND

Post-irradiation morphea (PIM) is an entity documented in the literature although still not mentioned in most of the dermatological textbooks with a frequency approximately 2 out of every 1000 patients who received radiotherapy. Most of the cases are misdiagnosed as recurrent or metastatic carcinoma.

MAIN OBSERVATIONS

We report on a 64-year-old woman who was treated with radiotherapy for breast cancer. Two years and eight months after the first dose of radiotherapy, she developed localized morphea in the irradiated area.

CONCLUSION

We report on a new case with a literature review and discuss pathogenesis, treatment modalities and post irradiation subcutaneos reactions mimicking PIM. Around 54 cases of post-irradiation morphea (PIM) were identified in the literature.

Photochemotherapy for systemic sclerosis: effect on clinical and molecular markers

BACKGROUND

The cutaneous changes seen in systemic sclerosis (SSc) can result in considerable patient morbidity.

AIM

We previously reported on the beneficial effect of psoralen ultraviolet A (PUVA) phototherapy in 13 patients with morphoea. We now report the findings of a study in which patients with SSc were treated with PUVA.

METHODS

Twelve patients with SSc were treated with PUVA phototherapy. The effect on cutaneous disease activity was assessed using the modified Rodnan score, and the effect on serological and immunohistochemical growth factors and adhesion molecules was also measured.

RESULTS

The median Rodnan score at baseline was 24.5 [interquartile range (IQR) 18.5-26.0]. The median number of treatments with PUVA was 24 exposures (IQR 20-26) with a median cumulative exposure of 68.3 J/cm(2) (IQR 28.6-139.8). Of the 12 patients, 11 responded well to phototherapy with a mean change in Rodnan score of 6.58 (36.98%) (P < 0.01, Wilcoxon signed ranks test). After treatment with PUVA there was a significant increase in circulating tumour necrosis factor-alpha levels in 8/12 patients (P = 0.03). In 7/12 patients there was an increase in E-selectin and vascular cell adhesion molecule, although this was not significant.

CONCLUSIONS

PUVA treatment is associated with a significant improvement in cutaneous symptoms in patients with SSc as measured by the Rodnan score (P < 0.01). Specific lymphocyte markers, adhesion molecules and cytokines are also affected by this treatment, helping to clarify further the mechanism of action of PUVA treatment and our understanding of the primary pathological process.

Acanthosis nigricans associated with primary hypogonadism: successful treatment with topical calcipotriol

Acanthosis nigricans is a mucocutaneous dermatosis characterized by hyperpigmentation and a velvety papillomatous hyperkeratosis. It is frequently associated with systemic diseases including malignancy and endocrinal disorders. We report the beneficial effect of topical calcipotriol ointment 50 mcg/g twice a day in acanthosis nigricans associated with primary hypogonadism.