Comparative Efficacy of Calcipotriol Ointment and Betamethasone 17-Valerate Ointment in the Treatment of Lichen Amyloidosus: A Prospective, Double-Blind, Right-Left Comparison Pilot StudyBULLETIN FOR MEDICAL PRACTITIONERS Dr Khoo Boo Peng, Registrar Introduction LA is common among the Chinese.[2,3] In Singapore, a study of 142 biopsy-confirmed patients seen between 1966 and 1969 noted a higher proportion of Chinese than 4 other ethnic groups.[4] Thirty five percent of 40 patients showed clinical improvement with topical betamethasone used under occlusion within 8 weeks, but a third relapsed just as fast on cessation of treatment. [5] Other treatment modalities which have been described include laser ablation, dermabrasion, topical dimethyl sulphoxide, oral etretinate and phototherapy but the results are frequently unsatisfactory. Calcipotriol ointment, a vitamin D analogue, is now an established mode of treatment for hyperkeratotic and hyperproliferative skin disorders such as psoriasis. It is also reported effective in disorders of cornification such as the various congenital ichthyoses.[6] The aim of this study is to determine the efficacy and safety of calcipotriol on LA in comparison with betamethasone 17-valerate. Materials and Methods Thirty grams of each ointment was dispensed per 4-weekly visit. Patients were instructed to apply twice daily to each affected limbs using the ipsilateral hand respectively in order to avoid cross contamination. Patients were assessed at weeks 0, 4, 8 and 12 for the right and left limbs. The extent of the lesions were assessed by the same physician with respect to:
The lesions were also similarly assessed by the patient with respect to:
Clinical photographs were taken during each review. Any score differences observed between week 0 and week 12 within each treatment group were analyzed by Wilcoxon Signed Ranks test for statistical significance, while differences in scores between the 2 treatment groups were analyzed by Mann Whiteney U test. Results The mean roughness score is defined as the average sum of the roughness score of all 16 patients for each treated side. Likewise the mean hyperpigmentation score and the mean pruritus score are defined as the average sum of hyperpigmentation and the average sum of pruritus respectively.
In the physician's assessment, the mean roughness scores at week 0 were 6.2 +- 2.7 for the calcipotriol side and 6.3 +- 2.9 for the betamethasone side. The mean hyperpigmentation scores at week 0 were 6.8 +- 1.8 for the calcipotriol side and 6.9 +- 1.8 for the betamethasone side (Fig 1 and 2). At the end of week 12, both sides had significantly reduced hyperpigmentation but only the calcipotriol side experienced significant reduction in roughness (Table 1 and Fig 3). However, there were no statistically significant differences between calcipotriol and betamethasone for all the weeks with regards to both treatment responses.
The patient's assessment of roughness, hyperpigmenatation and pruritus were favourable for both treated sides at the end of week 12 compared to week 0 (Table 2). However again there was no statistical significance between calcipotriol and betamethasone in treatment responses. In the assessment of adverse events, 3 patients experienced mild degree of redness and scaling of which 1 patient had an additional complaint of itch with calcipotriol ointment. These side effects were mild and all managed to continue with the study. None of the patients experienced any adverse effects with betamethasone ointment. Discussion The reduction in roughness and hyperpigmentation imply that calcipotriol inhibits the epidermal proliferation and hyperkeratosis, as in psoriasis. Although the reduction in roughness, hyperpigmentation and pruritus are statistically significant, the magnitude of change is small and therefore may not be apparent clinically. Lichen amyloidosus is often compounded by the problem of chronic, habitual scratching and is believed to be a form of lichen simplex chronicus.[7] The mild redness and scaling noted with calcipotriol in 3 patients may actually lead to further scratching and aggravation of the lesions. In contrast, betamethasone does not give rise to irritation. Other treatment modalities have been tried with variable results. Destructive therapy with carbon dioxide laser[8] and dermabrasion[9] have been reported in small series. Topical dimethyl suiphoxide (DMSO) showed positive results in some patients[10] but not in others.[1 1-13] Systemic therapy with etreti nate seems to benefit some patients,[14,15] but its long-term use and its side effects is a major drawback. An anecdotal report commented on the benefit of using ultraviolet B light (UVB) which reduces pruritus in lichen amyloidosus[16] but no further work has been done thus far. Since betamethasone 1 7-valerate ointment costs 8 times less than calcipotriol ointment, topical betamethasone remain the safest, simplest and most cost effective treatment option todate. Conclusion Acknowledgement References
DEDICATED TO EXCELLENCE IN DERMATOLOGY |
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