Topical treatments for chronic plaque psoriasis

  • Review
  • Intervention




Chronic plaque psoriasis is the most common type of psoriasis, and it is characterised by redness, thickness, and scaling. First-line management of chronic plaque psoriasis is with topical treatments, including vitamin D analogues, topical corticosteroids, tar-based preparations, dithranol, salicylic acid, and topical retinoids.


To compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis, relative to placebo, and to similarly compare vitamin D analogues (used alone or in combination) with other topical treatments.

Search methods

We updated our searches of the following databases to February 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2011, Issue 2), MEDLINE (from 1948), EMBASE (from 1980), Science Citation Index (from 2008), Conference Proceedings Citation Index - Science (from 2008), BIOSIS (from 1993), Dissertation Abstracts via DialogClassic (all publication years), and Inside Conferences (all publication years).

We identified ongoing and unpublished studies from the UK Clinical Research Network Study Portfolio and the metaRegister of Controlled Trials. We checked the bibliographies of published studies and reviews for further references to relevant trials, and we contacted trialists and companies for information about newly published studies.

A separate search for adverse effects was undertaken in February 2011 using MEDLINE and EMBASE (from 2005).

Final update searches for both RCTs and adverse effects were undertaken in August 2012. Although it has not been possible to incorporate RCTs and adverse effects studies identified through these final searches within this review, we will incorporate these into the next update.

Selection criteria

Randomised trials comparing active topical treatments against placebo or against vitamin D analogues (used alone or in combination) in people with chronic plaque psoriasis.

Data collection and analysis

One author extracted study data and assessed study quality. A second author checked these data. We routinely contacted trialists and companies for missing data. We also extracted data on withdrawals and on local and systemic adverse events. We defined long-term trials as those with a duration of at least 24 weeks.

Main results

This update added 48 trials and provided evidence on 7 new active treatments. In total, the review included 177 randomised controlled trials, with 34,808 participants, including 26 trials of scalp psoriasis and 6 trials of inverse psoriasis, facial psoriasis, or both. The number of included studies counted by Review Manager (RevMan) is higher than these figures (190) because we entered each study reporting a placebo and an active comparison into the 'Characteristics of included studies' table as 2 studies.

When used on the body, most vitamin D analogues were significantly more effective than placebo, with the standardised mean difference (SMD) ranging from -0.67 (95% CI -1.04 to -0.30; 1 study, 119 participants) for twice-daily becocalcidiol to SMD -1.66 (95% CI -2.66 to -0.67; 1 study, 11 participants) for once-daily paricalcitol. On a 6-point global improvement scale, these effects translate into 0.8 and 1.9 points, respectively. Most corticosteroids also performed better than placebo; potent corticosteroids (SMD -0.89; 95% CI -1.06 to -0.72; I² statistic = 65.1%; 14 studies, 2011 participants) had smaller benefits than very potent corticosteroids (SMD -1.56; 95% CI -1.87 to -1.26); I² statistic = 81.7%; 10 studies, 1264 participants). On a 6-point improvement scale, these benefits equate to 1.0 and 1.8 points, respectively. Dithranol, combined treatment with vitamin D/corticosteroid, and tazarotene all performed significantly better than placebo.

Head-to-head comparisons of vitamin D for psoriasis of the body against potent or very potent corticosteroids had mixed findings. For both body and scalp psoriasis, combined treatment with vitamin D and corticosteroid performed significantly better than vitamin D alone or corticosteroid alone. Vitamin D generally performed better than coal tar, but findings relative to dithranol were mixed. When applied to psoriasis of the scalp, vitamin D was significantly less effective than both potent corticosteroids and very potent corticosteroids. Indirect evidence from placebo-controlled trials supported these findings.

For both body and scalp psoriasis, potent corticosteroids were less likely than vitamin D to cause local adverse events, such as burning or irritation. Combined treatment with vitamin D/corticosteroid on either the body or the scalp was tolerated as well as potent corticosteroids, and significantly better than vitamin D alone. Only 25 trials assessed clinical cutaneous dermal atrophy; few cases were detected, but trials reported insufficient information to determine whether assessment methods were robust. Clinical measurements of dermal atrophy are insensitive and detect only the most severe cases. No comparison of topical agents found a significant difference in systemic adverse effects.

Authors' conclusions

Corticosteroids perform at least as well as vitamin D analogues, and they are associated with a lower incidence of local adverse events. However, for people with chronic plaque psoriasis receiving long-term treatment with corticosteroids, there remains a lack of evidence about the risk of skin dermal atrophy. Further research is required to inform long-term maintenance treatment and provide appropriate safety data.








以下のデータベースを2011年2月まで検索した:Cochrane Skin Group Specialised Register、コクラン・ライブラリのCENTRAL(2011年第2号)、MEDLINE(1948年以降)、EMBASE(1980年以降)、Science Citation Index(2008年以降)、Conference Proceedings Citation Index – Science(2008年以降)、BIOSIS(1993年以降)、DialogClassicの論文抄録(全発表年)およびInside Conferences(全発表表年)。

進行中の研究および未発表の研究はUK Clinical Research Network Study PortfolioおよびmetaRegister of Controlled Trialsから検索した。 関連試験をさらに参照するため、既発表研究およびレビューの参考文献をチェックし、新たに発表された研究があれば、その情報を試験実施者および会社に問い合わせた。








今回の更新では48試験を追加し、7種類の新たな実薬治療薬に関してエビデンスが得られた。これらを合わせると、本レビューには177のRCT試験の参加者34,808例の情報が含まれることになった。このうち26試験は頭皮乾癬に関する試験であり、6試験は逆性乾癬、顔面乾癬または両方に関する試験であった。Review Manager(RevMan) を用いて数えた研究数はこれより多いが(190研究)、これはレビューアらが、プラセボとの比較および実薬との比較を報告した研究を2つの研究として「レビューに含めた研究の特性」表に算入したためである。

体部に用いたビタミンDアナログのほとんどはプラセボと比較して有意な効果を示し、標準化平均差(SMD)の範囲は、ベコカルシジオール1日2回で-0.67(95%CI -1.04~-0.30;1研究,119例)~パリカルシトール1日1回で-1.66(95%CI -2.66~-0.67;1研究、11例)であった。6点制の総合改善尺度では、これらの効果はそれぞれ0.8点および1.9点であった。ステロイドのほとんどでもプラセボより良好な効果が認められたが、強力なステロイドの効果(SMD -0.89;95%CI -1.06~-0.72;I²統計量=65.1%;14研究、2,011例)は非常に強力なステロイドの効果(SMD -1.56;95%CI -1.87~-1.26);I²統計量=81.7%;10研究、1,264例)より小さかった。6点制の総合改善尺度では、これらの効果はそれぞれ1.0点および1.8点であった。ジトラノールとビタミンD/ステロイドの併用およびタザロテンは、いずれもプラセボと比較して有意に効果が高かった。






《注意》この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、eJIM事務局までご連絡ください。なお、2013年6月からコクラン・ライブラリーのNew review, Updated reviewとも日単位で更新されています。eJIMでは最新版の日本語訳を掲載するよう努めておりますが、タイム・ラグが生じている場合もあります。ご利用に際しては、最新版(英語版)の内容をご確認ください。








我们对检索进行了更新,检索时间更新至2011年2月,数据库包括:Cochrane皮肤组专业注册库(the Cochrane Skin Group Specialised Register)、Cochrane临床对照试验中心注册库(CENTRAL,2011年2期)、MEDLINE(自1948年起)、 EMBASE(自1980年起)、科学引文索引数据库(Science Citation Index,自2008年起)、科技会议录索引数据库(CPCI-S,自2008年起)、美国生物科学数据库(BIOSIS,自1993年起)、通过DialogClassic平台获得的论文摘要(Dissertation Abstracts via DialogClassic,所有出版年)以及内部会议(Inside Conferences,所有出版年)。

我们纳入了英国临床研究网络委员会(the UK Clinical Research Network Study Portfolio)和对照试验metaRegister(themetaRegister of Controlled Trials)收录的进行中和未发表的研究。我们筛查了已发表研究和综述的参考文献以便进一步引用相关试验为进一步引用相关试验提供参考。我们还联系了研究者和公司以获取最新发表的研究的信息。






一名作者提取了资料并评估了纳入研究的质量进行了资料提取以及纳入研究的质量评估。第二作者检查了这些数据。我们按照常规联系了试验者和公司,以获取缺失数据。我们还从中断的试验及局部和系统性不良反应事件中提取了资料。我们将长期试验(long-term trial)定义为研究时间至少为24周的临床试验。


本次更新增加了48项试验,并提供了7例阳性治疗的证据为7种阳性治疗方法提供了证据。总体上,这篇综述包括177项随机对照试验,共含34808名受试者纳入了共涉及34808名受试者的177项随机对照试验,其中包括26例头皮银屑病和6例皮褶性银屑病、面部银屑病或面部皮褶性银屑病。因为我们在“纳入研究特征表”中,把每一项同时报告了安慰剂对照和阳性比较对照的研究都计作了两项研究,所以由Review Manager(RevMan,Meta分析专用软件)统计的纳入研究的数量高于190项。

用于身体皮肤时,大多数维生素D类似物明显比安慰剂更有效,标准化均数差(SMD)的变化范围从每天使用两次becocalcidiol可卡醛类激素(becocalcidiol)的-0.67(95%可信区间(95% CI)从-1.04到-0.30;包含一项研究,共包括涉及119名受试者)到每天使用一次帕立骨化醇的-1.66(95% CI从-2.66到-0.67;包含一项研究,共包括涉及11名受试者)。在整体疗效评估量表(0-6分)中,这些影响分别转化为0.8点和1.9点达到了0.8分和1.9分。大多数皮质类固醇疗效也都优于安慰剂;强效皮质类固醇(SMD=-0.89;95% CI从-1.06到-0.72;I²统计数据=65.1%;包含14项研究,共包括涉及2011名受试者)比起极强效皮质类固醇(SMD=-1.56;95% CI从-1.87到-1.26,I²统计数据=81.7%;包含10项研究,共包括涉及1264名受试者)优势很小。在整体疗效评估量表(0-6分)中,这些优势分别转化为1.0点和1.8点达到了1.0分和1.8分。地蒽酚与维生素D 类似物或皮质类固醇联合治疗以及他扎罗汀单独使用的疗效全都显著优于安慰剂。







Plain language summary

Skin treatments for chronic plaque psoriasis

Chronic plaque psoriasis is the most common type of psoriasis. Although any part of the body may be affected, the most commonly affected sites are the elbows, knees, and scalp. 'Topical' treatments (i.e. treatments applied to the skin) are usually tried first. These include vitamin D products, topical corticosteroids, tar-based preparations, dithranol, salicylic acid, and vitamin A products. As chronic plaque psoriasis is a long-term condition, it is important to find out which treatments work best and what adverse effects they have. This review describes average benefits of different treatments, while recognising that individuals will vary in their experience of each treatment.

The evidence was based on 177 studies, which, in total, included 34,808 people. Studies were typically about 7 weeks' long, but this ranged from 1 week to 52 weeks. Vitamin D products were found to work better than placebo (the base cream or ointment). Potent topical corticosteroids (strong, e.g. betamethasone dipropionate) and very potent (very strong, e.g. clobetasol propionate) topical corticosteroids were also effective.

Some studies compared vitamin D products directly with potent or very potent corticosteroids. These products had similar effects when applied to the body, but corticosteroids worked better than vitamin D for scalp psoriasis. Treatment that combined vitamin D with a corticosteroid was more effective than vitamin D alone and more effective than the topical corticosteroid alone. Vitamin D products generally performed better than coal tar, but studies found conflicting results when comparing vitamin D with dithranol.

Whether applied to the body or to the scalp, potent corticosteroids were less likely than vitamin D to cause 'local adverse events', such as skin irritation or burning, and people were therefore more likely to stop using vitamin D products. When studies examined whether topical treatments had effects within the body ('systemic adverse events'), we found no difference between placebo and any other treatment. However, this may be because many trials did not properly assess systemic adverse events, rather than because there really was no difference.

More long-term studies would help doctors and people with psoriasis decide on the best way to treat this chronic condition.

Laički sažetak

Lijekovi koji se nanose na kožu za kroničnu psorijazu s plakovima

Kronična psorijaza s plakovima je najčešći tip psorijaze. Iako može zahvatiti bilo koji dio tijela, najčešće se pojavljuje na laktovima, koljenima i vlasištu. Najčešće se prvo proba topičko liječenje (tj. liječenje koje se primjenjuje na kožu). To uključuje proizvode koji sadrže vitamin D, lokalne kortikosteroide, preparate bazirane na katranu, dithranol, salicilnu kiselinu i proizvode koji sadrže vitamin A. Pošto je kronična psorijaza s plakovima dugotrajno stanje, važno je otkriti koje je liječenje najučinkovitije i kakve nuspojave ima. Ovaj Cochrane sustavni pregled analizirao je prosječnu djelotvornost različitih vrsta liječenja, pri čemu se uvažava činjenica da pojedini pacijenti mogu različito reagirati na liječenje.

Dokazi se temelje na 177 studija koje su uključile ukupno 34 808 ljudi. Studije su prosječno trajale oko 7 tjedana, ali je raspon trajanja bio između 1 i 52 tjedna. Pokazalo se da proizvodi koji sadrže vitamin D djeluju bolje od placeba (osnovna krema ili mast). Potentni topički kortikosteroidi (snažni, npr. betametazon dipropionat) i vrlo potentni (vrlo snažni, npr. klobetazol propionat) topički kortikosteroidi su također bili učinkoviti.

Neke studije su usporedile proizvode koje sadrže vitamin D s potentnim ili vrlo potentnim kortikosteroidima. Ti proizvodi imali su sličan učinak kada su se primijenili na tijelo, ali su kortikosteroidi bili učinkovitiji za psorijazu vlasišta. Liječenje koje kombinira vitamin D s kortikosteroidom je učinkovitije od samog vitamina D ili samog topičkog kortikosteroida. Proizvodi koji sadrže vitamin D su se pokazali boljima od katrana, ali su studije pokazale oprečne rezultate uspoređujući vitamin D s dithranolom.

Topički kortikosteroidi, namazani na tijelo ili vlasište, rjeđe su uzrokovali lokalne nuspojave kao što su iritacija kože ili osjećaj pečenja od vitamina D. Stoga su pacijenti bili skloniji prestati koristiti proizvode koje sadrže vitamin D. U studijama nije utvrđena razlika između placeba i drugih vrsta liječenja s obzirom na učinke tih vrsta liječenja na tijelo (sustavne nuspojave). Međutim, to bi moglo biti zato što mnoga istraživanja nisu propisno procijenila takve nuspojave, a ne zato što zbilja nije bilo razlike.

Potrebno je provesti više dugotrajnih studija koje bi pomogle liječnicima i oboljelima od psorijaze kako bi odlučili koji je najbolji način liječenja ovog kroničnog stanja.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Maja Ilijanić
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《注意》この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、eJIM事務局までご連絡ください。なお、2013年6月からコクラン・ライブラリーのNew review, Updated reviewとも日単位で更新されています。eJIMでは最新版の日本語訳を掲載するよう努めておりますが、タイム・ラグが生じている場合もあります。ご利用に際しては、最新版(英語版)の内容をご確認ください。