Comparative study of efficacy of hand foot psoralen ultraviolet a therapy versus sequential therapy of topical clobetasol propionate with topical calcipotriol ointment in palmoplantar psoriasis

BACKGROUND: Psoriasis is a common genetically determined chronic inflammatory skin disease. It is characterized by well defined erythematous plaque with silvery white scales. It is commonly distributed over the elbow, knee, lower back, nails, scalp, palms and soles. It is associated with varying periods of remission and relapse. Various modalities of treatment have been tried. The main goal of therapy is rapid control of the disease and to maintain a longer duration of remission. Treatment of palmoplantar psoriasis and remission maintenance is very difficult. AIM OF THE STUDY: The aim of the study is to compare the efficacy of topical psoralen and ultraviolet A phototherapy with sequential therapy of topical 0.05% clobetasol propionate ointment and topical 0.005% calcipotriol ointment in palmoplantar psoriasis and to observe the adverse effects, remission maintenance and PASI percentage reduction of more than 50% in both groups. MATERIALS AND METHODS: 50 patients are included in the study. The population for the study included patients attending outpatient Department of Dermatology, Coimbatore Medical College Hospital, Coimbatore. The patients are divided into two groups, group A and group B. The treatment duration was 6 months and the follow up period was 6 months. Each group has 25 patients. Group A patients received topical hand foot PUVA therapy with minimum dose of 1J/cm2 with increment dosage of 0.5J/cm2, in the frequency two times per week and the maximum dose of 24.5J/cm2 in some patients. Eyes were protected by using goggles during treatment. In group B sequential therapy of calcipotriol ointment combinations given in three phases, in phase 1 combination of clobetasol propionate and calcipotriol ointment once a day application in the first month, in phase 2 clobetasol propionate for weekends and calcipotriol for week days once a day application in the second and third month, in phase 3 calcipotriol ointment once a day application in the fourth, fifth and sixth month. PASI score and PASI percentage reduction was assessed at the end of 8th, 16th, 24th weeks. RESULTS: During treatment, 3 patients in group A and 1 patient in group B lost follow up. In both groups none of the patients showed complete clearance of both palms and plantar lesions. In group A out of 22 patients, 20 (90%) showed more than 50% reduction of PASI score. Four patients showed complete clearance of lesion in the palms. Two patients showed complete clearance of lesion in the soles. The average period of clearance of lesions was at 19 weeks. In six months follow up period 3 patients showed relapse after 15 weeks of average period of remission. 4 patients showed adverse effect like erythema and burning sensation. In group B out of 24 patients, all (100%) showed more than 50% reduction of PASI score. Seven patients showed complete clearance of lesion in the palms and five patients showed complete clearance of lesion in the soles. The average period of clearance of lesions was at 20.3 weeks. In six months follow up period 2 patients showed relapse after 20 weeks of average period of remission. 3 patients showed adverse effect like erythema,itching and burning sensation. CONCLUSION: The efficacy of topical calcipotriol ointment and steroid used in sequential manner is better than the topical psoralen ultraviolet A therapy. All the patients (100%) in calcipotriol and steroid combination group showed more than 50% reduction of PASI score. But in PUVA therapy group 90% of patients showed more than 50% reduction of PASI score. On comparing the adverse effects, patients on PUVA therapy group developed more adverse effects than the patients on calcipotriol and steroid combination group. The duration of remission maintenance was long in calcipotriol and steroid combination group when compared to PUVA therapy group. In our study, we arrived at the conclusion that topical therapies used in a sequential manner was more effective and it may be considered as a first line therapy for the treatment of patients with palmoplantar psoriasis