Safety and efficacy profile of oral cyclosporine vs oral methotrexate vs oral acitretin in palmoplantar psoriasis: A hospital based prospective investigator blind randomized controlled comparative study

Abstract

Palmoplantar psoriasis (PPP) is a variant of psoriasis which affects only 5% body surface area, but has a devastating impact on affected individual's quality of life. There are few studies assessing efficacy of individual drugs, and few comparative studies of efficacy of two drugs in the literature, however randomized control trial comparing all three drugs against each other has not been done. A total of 75 patients of PPP were enrolled for study and randomly divided into three groups A, B, C of 25 each and assigned for treatment with cyclosporine (CSA) (2.5‐5 mg/kg/d), methotrexate (MTX)(7.5‐15 mg/week), and acitretin (ACT) (25‐50 mg/d), respectively. Modified psoriasis area and severity index (PASI), psoriasis severity scale, visual analogue scale, physician global assessment, and PPQOL were used for monitoring response to therapy and improvement in quality of life up to end of study, and thereafter monthly follow‐up was done to find duration of remission for next 90 days. Side effects if any were recorded. There was a statistically significant difference in modified PASI for CSA, MTX, and ACT. The mean modified PASI at baseline was 12.8 ± 4.8 for CSA, 12.57 ± 3.8 for MTX, and 11.92 ± 3.28 for ACT (P = .75). Mean modified PASI reduced to 2.91 ± 1.8 for CSA, 6.57 ± 2.2 for MTX, and 4.7 ± 2.2 for ACT at week 5 (P = <.01). Mean modified PASI further reduced to 0.095 ± 0.35 for CSA, 2.12 ± 1.4 for MTX, and 0.78 ± 0.97 for ACT at end of study (P = <.01). However, average duration of remission was 9 weeks for ACT group, followed by 6.47 and 3 weeks for CSA and MTX group, respectively. Adverse events were comparatively more in ACT group as compared to MTX and CSA groups. PPP affects quality of life tremendously and warrants systemic treatment for the same. CSA provides fastest resolution of lesions and have highest efficacy. MTX and ACT have similar efficacy, but ACT provides longer duration of remission.

Exploring the Links between Obesity and Psoriasis: A Comprehensive Review

“…Methotrexate, cyclosporine and acitretin are drugs commonly used in the treatment of psoriasis; acitretin has a longer-lasting effect, and the effect of cyclosporine on lesions is faster, while methotrexate and acitretin have a similar effect [ 133 ]. However, these drugs can cause non-alcoholic fatty liver disease and liver fibrosis in obese patients when administered at high doses [ 45 ].…”

Impact of Adverse Events Associated With Acitretin Treatment of Moderate-to-Severe Plaque Psoriasis: Based on an Observational, Single-Center Study in Shanghai, China

“…However, the severity of such AEs was generally dose-dependent and was successfully treated by symptomatic treatments, as previously reported by studies performed in China and other countries. 4,22,[24][25][26][27] The next most commonly affected systems/tissues were the endocrine and digestive systems, especially represented by dyslipidemia and elevated liver enzymes. AEs affecting the nerves, circulation, and mental status were less commonly reported.…”

“…It has been previously reported that most patients have adverse reactions of varying degrees to acitretin. 13,[19][20][21][22] These adverse reactions are usually dose-dependent and reversible and can disappear or alleviate after dose reduction or initiation of intermittent therapy. 4,8 However, drug reduction or discontinuation due to adverse reactions is typical in clinical practice.…”

Successful Treatment of Palmoplantar Pustulosis With Apremilast

“…7 Systemic agents including methotrexate, acitretin, and cyclosporine have all shown efficacy, however, the adverse side effects associated with the aforementioned agents makes their use disfavorable. 8 Side effects of apremilast, on the other hand, primarily consist of diarrhea and depression, which are typically…”