Interventions for guttate psoriasis (Review) The Cochrane Library 2013, Issue 10

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Interventions for guttate psoriasis (Review) The Cochrane Library 2013, Issue 10
Interventions for guttate psoriasis (Review)
Chalmers R, O’Sullivan T, Owen CM, Griffiths CEM
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 10
http://www.thecochranelibrary.com
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 n-3 fatty acid infusion vs n-6 fatty acid infusion, Outcome 1 Change in semi-quantitative
psoriasis severity score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.2. Comparison 1 n-3 fatty acid infusion vs n-6 fatty acid infusion, Outcome 2 Change in patient-scored
subjective severity score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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[Intervention Review]
Interventions for guttate psoriasis
Robert Chalmers1 , Teresa O’Sullivan2 , Caroline M Owen3 , Christopher EM Griffiths1
1
The Dermatology Centre, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester, UK. 2 Department of
Behavioural Medicine, Salford Royal NHS Foundation Trust, Manchester, UK. 3 Royal Blackburn Hospital, Blackburn, UK
Contact address: Robert Chalmers, The Dermatology Centre, The University of Manchester, Salford Royal NHS Foundation Trust,
Stott Lane, Salford, Manchester, M6 8HD, UK. [email protected]
Editorial group: Cochrane Skin Group.
Publication status and date: Edited (no change to conclusions), published in Issue 10, 2013.
Review content assessed as up-to-date: 3 January 2000.
Citation: Chalmers R, O’Sullivan T, Owen CM, Griffiths CEM. Interventions for guttate psoriasis. Cochrane Database of Systematic
Reviews 2000, Issue 2. Art. No.: CD001213. DOI: 10.1002/14651858.CD001213.
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Guttate psoriasis is a distinctive acute form of psoriasis which characteristically occurs in children and young adults. Very little specific
evidence-based guidance is available in standard texts to help make rational decisions about treatment options.
Objectives
To assess the effectiveness of treatments for guttate psoriasis.
Search methods
We searched the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966- September 1999), Embase
(1988-September 1999), Salford Database of Psoriasis Trials (to November 1999) and European Dermato-Epidemiology Network
(EDEN) Psoriasis Trials Database (to November 1999) for terms GUTTATE and PSORIASIS. We also searched 100 unselected RCTs
of psoriasis therapy and all 112 RCTs of phototherapy for psoriasis in the Salford Database of Psoriasis Trials for separate stratification
for guttate psoriasis.
Selection criteria
Randomised trials in which patients with acute guttate psoriasis were randomised to different treatments, except those trials examining
antistreptococcal interventions which are addressed in a separate Cochrane review.
Data collection and analysis
Two reviewers independently assessed trial eligibility and quality.
Main results
No published report could be found to support or to challenge current commonly used methods of management.
Only one trial which met the selection criteria was identified. In this small study of 21 hospitalised patients with guttate psoriasis,
intravenous infusion of an n-3 fatty acid rich lipid emulsion was compared with placebo emulsion containing n-6 fatty acids. The n-3
preparation appeared to be of some benefit for patients with guttate psoriasis.
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1
Authors’ conclusions
There is currently no firm evidence on which to base treatment of acute guttate psoriasis. Studies comparing standard treatment
modalities, including phototherapy and topical regimens, are required to enable informed decisions on treatment choices to be made.
PLAIN LANGUAGE SUMMARY
Treatments for guttate psoriasis
Psoriasis is a skin disease that causes scaly pink patches. Guttate psoriasis is a particular form of the disease that usually affects children
and young adults. It can happen on its own, or as a complication of ordinary (chronic plaque) psoriasis. Often, it follows a bacterial
throat infection or tonsillitis. Antibiotics and tonsillectomy as treatments for guttate psoriasis are covered by another review. This review
could find no evidence, from trials, about the effects of any other commonly used treatments for guttate psoriasis.
BACKGROUND
Description of the condition
Guttate psoriasis is a distinctive form of psoriasis which characteristically occurs in children and young adults. It may arise on
its own (acute guttate psoriasis) or may complicate existing, often quite limited, chronic plaque psoriasis (guttate flare of chronic
psoriasis).
It is strongly associated with preceding or concurrent streptococcal infection, evidence of which can be found in a majority of affected patients (Telfer 1992). Typically, showers of tiny red papules
(likened to rain-drops or guttate) erupt over large areas of the skin
surface one to two weeks after an episode of acute tonsillitis. In the
early stages before the typical scale has had a chance to develop,
guttate psoriasis can be mistaken for a drug eruption especially in
people given an antibiotic for the associated streptococcal infection. The true diagnosis, which is a clinical one, soon becomes
apparent as characteristic psoriatic scaling develops on the surface
of the papules. Guttate psoriasis may be itchy and may have a
profound effect on self-esteem, especially in the psychologically
vulnerable age group in which it most commonly occurs.
If left untreated, guttate psoriasis may clear spontaneously or may
develop into chronic plaque psoriasis. Either form may recur although the risk is not well defined (Martin 1996).
nol) and topical corticosteroids may also be used (with or without
UVB phototherapy). Other forms of phototherapy used include
narrow-band UVB, psoralen plus ultraviolet A (PUVA) and psoralen bath PUVA (all with or without the oral retinoid, acitretin
or, formerly, etretinate). More recently vitamin D analogues (calcipotriol, tacalcitol) have been introduced for treating psoriasis
and are used by some dermatologists for guttate psoriasis.
How the intervention might work
In view of the associated streptococcal infection some dermatologists advocate the use of antibiotic therapy or tonsillectomy. The
optimal method for achieving clearance of guttate psoriasis is not
known. Furthermore it is not clear whether any interventions can
effectively prolong the duration of remission or prevent progression to chronic plaque psoriasis.
Why it is important to do this review
There is remarkably little guidance in standard texts as to how
this distinctive form of psoriasis should be treated and whether
it should be managed differently from chronic plaque psoriasis
(Camp 1998).
Interventions aimed at treating or preventing the associated streptococcal infection are addressed in a separate Cochrane review
(Owen 2000).
Description of the intervention
There is no consensus on the best treatment for guttate psoriasis.
Commonly, various forms of tar are applied topically in conjunction with ultraviolet B (UVB) phototherapy. Anthralin (dithra-
OBJECTIVES
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Primary objectives
To assess the effectiveness of any treatment aimed at clearing psoriasis from the skin of patients with acute guttate psoriasis or an
acute guttate flare of chronic psoriasis.
To establish whether there is any evidence to support the use of
commonly used treatments of guttate psoriasis such as topical tars,
anthralin or vitamin D analogues with or without UVB or other
phototherapy.
Secondary objectives
To define, so far as is possible, the optimal regimen for treating
guttate psoriasis based not only on objective measures of disease
improvement but also on patient-perceived benefits to health and
quality of life set against the acceptability or inconvenience of each
treatment method.
To examine the implications for dermatological practice of any
recommendations made, including the associated healthcare costs
of each treatment method.
To examine whether treatment method affected subsequent clinical course (by either prolonging remission or preventing progression to chronic plaque psoriasis)
To determine what further study is required to enable dermatologists to make informed choices between existing treatments.
Types of outcome measures
Primary outcomes
There is no information as to what percentage reduction in psoriasis severity score is perceived by people with psoriasis as being
“worthwhile”. It may be possible to achieve a modest reduction
in objective psoriasis severity score which, whilst achieving statistical significance, does not have a significant impact on either the
patient’s or the physician’s perception of overall disease severity.
There is enormous variation between patients in their perceptions
of what constitutes a satisfactory response to treatment. Guttate
psoriasis is a condition where near complete clearance of disease
may be expected in a majority of treated patients. Therefore, where
scores were given, a relative treatment difference of at least 50%
for comparison between active treatment versus placebo, or at least
20% between two or more active treatments was accepted as being
the minimum clinically meaningful change. (These figures were
derived by discussion within the Cochrane Skin Group.)
The nominated primary outcome measures agreed in consultation
with the Group were thus:
1. Improvement or clearance of psoriasis as measured by
reduction in the Psoriasis Area Severity Index (PASI) score or
other objective semi-quantitative measure of disease severity
2. Reduction in patients’ self-assessed (or parent/guardianassessed) psoriasis severity scores over the time course of the
intervention.
3. Improvement in patient satisfaction measures and quality of
life assessment measures over the time course of the intervention.
METHODS
Secondary outcomes
Criteria for considering studies for this review
Types of studies
Randomised trials which examine interventions other than those
aimed specifically at eradicating streptococcal infection which are
addressed in a separate review (Owen 2000).
1. Proportion of patients developing chronic plaque psoriasis
within one year of acute guttate psoriasis.
2. Proportion of patients with no further episodes of guttate
psoriasis within a series of defined periods (one year, five years,
ten years).
3. Implications for healthcare costs of different treatments
which are shown to be effective.
Search methods for identification of studies
Types of participants
Children and adults with a clinical diagnosis of acute guttate psoriasis or guttate exacerbation of chronic psoriasis.
Types of interventions
Any intervention other than those aimed at eradicating streptococcal infection.
Electronic searches
We searched the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966- September 1999), Embase (1988-September 1999), Salford Database of Psoriasis Trials
(to November 1999) and European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for
the terms GUTTATE and PSORIASIS using the Cochrane Skin
Group search strategy.
Interventions for guttate psoriasis (Review)
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A validation check was undertaken by cross-checking with the Salford Database of Psoriasis Trials for trials containing the keywords
GUTTATE PSORIASIS. The Salford Database is derived from
searches of Medline (from 1966-1999) and Embase (from 19801999) using the terms STUDY or TRIAL* or RANDOM* in the
text, COMPAR* in the title or CLINICAL-TRIAL in the subject
heading; the Cochrane Controlled Trials Register; and the EDEN
Psoriasis Trials Database. All retrieved studies had been screened
and coded by disease type including GUTTATE PSORIASIS.
Searching other resources
In addition the full text of 100 unselected RCTs of psoriasis therapy and all trials of phototherapy for psoriasis from the Salford
Database were scrutinised for evidence of separate stratification for
guttate psoriasis in order to examine whether such studies might
contain sub-groups which were not declared in the title or abstract
and had not been detected in the keyword coding process.
References in retrieved articles were scrutinised for evidence of
studies which may have been missed by these procedures. The authors of relevant trials, members of the Cochrane Skin Group and
dermatologists interested in psoriasis were approached informally
and asked whether they were aware of any other relevant data. We
also asked Professor Chris Silagy to conduct a search for guttate
psoriasis in his database of trials conducted in primary care.
Data collection and analysis
We considered whether studies of guttate psoriasis treatment may
have been hidden within RCTs for psoriasis but were unable to
find any evidence for this from scrutiny of 100 unselected RCTs
of psoriasis therapy.
The only trial which we were able to find involved treatment of
people with guttate psoriasis by hospitalisation for 10 days, during which they received twice daily intravenous infusions of lipid
emulsions rich in either n-3 (“active”) or n-6 (placebo) fatty acids
(Grimminger 1993). Please see Characteristics of included studies.
One trial (Melski 1977) was excluded, please see Characteristics
of excluded studies.
Risk of bias in included studies
The single trial was of satisfactory quality with adequate concealment of allocation.
Effects of interventions
No trials of standard therapies for guttate psoriasis were available
for consideration.
Intravenous n-3 fatty acid supplementation produced a rapid beneficial effect (improvement in severity scores of between 45% and
76% over ten days) in patients with acute guttate psoriasis. This
degree of improvement was not seen in patients receiving placebo
(n-6) supplementation (16% to 25% over ten days)(Grimminger
1993). Please see Analysis 1.1 and Analysis 1.2.
Selection of studies
All identified studies were scrutinised to ensure that diagnostic
criteria, randomisation methods and outcome measurements enabled a satisfactory comparison of interventions.
All relevant studies were evaluated using guidelines set out in the
Cochrane Collaboration Handbook and were assessed independently by two members of the Group before being accepted into
the review.
Subgroup analysis of patients with and without preexisting chronic
plaque psoriasis (“guttate flares” vs “acute guttate psoriasis” ) would
be performed if available data allowed.
Where these details were not clear from the publication, authors
were asked to provide further clarification.
RESULTS
Description of studies
No trials of topical therapy or phototherapy were identified.
DISCUSSION
Summary of main results
The single study which was found (Grimminger 1993) was not
designed to compare established methods of treating guttate psoriasis but was intended to test the hypothesis that fish oil-derived
n-3 fatty acids might be beneficial for acute guttate psoriasis. Furthermore, only adults (mean age 39.7 years) were recruited and
it was thus not representative of acute guttate psoriasis, a disease
seen mainly in children and young adults. It is of theoretical interest that this trial appeared to show benefit from treatment with
intravenous n-3 fatty acids but, when costs of hospitalisation and
inconvenience to the patient are considered, it is clear that this
cannot be recommended in the routine management of guttate
psoriasis. It is known that fish oil exerts a mild beneficial effect in
chronic plaque psoriasis (Bittiner 1988,Gupta 1989) and it is certainly possible that the effects may be more pronounced in acutely
flaring psoriasis. It might be appropriate to look at the effects of
oral n-3 fatty acids in patients with acute guttate psoriasis.
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
4
Overall completeness and applicability of
evidence
Despite the fact that the appearance and clinical course of guttate
psoriasis is known to differ from that of chronic plaque psoriasis, many studies treat patients with these diseases as one group.
Although there are studies that include patients with guttate psoriasis, they are seldom stratified separately to different treatment
groups. To give an example, a study examining various forms of
phototherapy and systemic retinoids (Green 1992) recruited 45
patients with chronic plaque or guttate psoriasis and allocated each
to one of three treatment groups. From the report it was impossible to determine how many patients had guttate psoriasis or into
which group they had been allocated. We looked very carefully for
studies in which patients with guttate psoriasis were randomised to
receive different treatments but were unable to identify any study
in which treatments in common use for acute guttate psoriasis
were compared. It is possible that some RCTs of treatments for
psoriasis may have contained subgroups in which patients with
acute guttate psoriasis were independently randomised and evaluated, but scrutiny of 100 unselected psoriasis trials failed to uncover any such study. Furthermore we were unable to detect any
such study in an extensive departmental database of psoriasis trials which had been methodically tagged by keywords including
“guttate psoriasis”. As an additional check, we read all 112 trials
of phototherapy for psoriasis (UVB or Psoralen plus UVA) in our
database, since these were the studies where one might have expected patients with guttate psoriasis to be represented. One large
study of 1308 patients receiving PUVA therapy (Melski 1977) did
include over 120 patients with guttate psoriasis but, although response to treatment in the guttate group was evaluated separately,
the allocation of these patients to different treatment groups was
not stratified.
It is surprising that there appears to have been virtually no research
into the treatment of a relatively common and well-defined entity.
There is no firm evidence to guide physicians treating patients
with acute guttate psoriasis.
dressed.
How do standard topical therapies (e.g. tar, topical corticosteroids,
anthralin) compare with vehicle alone or newer therapies (e.g.
vitamin D analogues)?
What is the role of phototherapy in acute guttate psoriasis? Which
modality should be used? Should it be broad-band or narrowband UVB? Is there a place for photochemotherapy (oral or bath
psoralens with ultraviolet light A)?
Should topical therapy be administered in conjunction with phototherapy and, if so, what is the optimal regimen?
Is there a role for systemic retinoid therapy?
Can any intervention prolong the duration of remission from guttate psoriasis or prevent progression to chronic plaque psoriasis?
We suggest that the most pressing priorities are as follows:
1. Comparison of tar alone, topical corticosteroid alone,
calcipotriol alone and vehicle alone
2. Comparison of the two most effective of the treatments
from above study with UVB
thus: best treatment alone, best treatment + UVB, next best treatment + UVB, vehicle + UVB
In view of the apparent benefit of intravenous n-3 fatty acids in
acute guttate psoriasis and the known mild beneficial effects of
oral fish oil in chronic plaque psoriasis, it would also be worth
performing a study comparing oral fish oil against placebo oil in
acute guttate psoriasis.
It is also important to examine the place of antibiotic therapy in
patients with guttate psoriasis and tonsillectomy for those with
recurrent attacks. This is addressed in a separate Cochrane review
(Owen 2000).
AUTHORS’ CONCLUSIONS
ACKNOWLEDGEMENTS
Implications for practice
To Boots Healthcare for funding Teresa O’Sullivan as part-time
research assistant to the Cochrane Skin Group.
There is no firm evidence on which to make any recommendations
for the routine treatment of guttate psoriasis.
To Ms Christine Clark for assisting in data retrieval.
Implications for research
To Professor Luigi Naldi for providing access to the EDEN psoriasis trials database.
There is a requirement for the most basic of questions to be ad-
To colleagues for useful suggestions and support.
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
5
REFERENCES
References to studies included in this review
Grimminger 1993 {published data only}
Grimminger F, Mayser P, Papavassilis C, Schlotzer E, Heuer
KU, Fuhrer D, et al.A double-blind, randomised, placebocontrolled trial of n-3 fatty acid based lipid infusion in
acute, extended guttate psoriasis. Rapid improvement
of clinical manifestations and changes in neutrophil
leukotriene profile. Clin Invest (Germany) 1993;71:634–43.
References to studies excluded from this review
Melski 1977 {published data only}
Melski JW, Tanenbaum L, Parrish JA, Fitzpatrick TB,
Bleich HL. Oral methoxypsoralen photochemotherapy
for the treatment of psoriasis: a cooperative clinical trial.
Journal of Investigative Dermatology 1977;68:328–35.
Additional references
Bittiner 1988
Bittiner SB, Tucker WFG, Cartwright I, Bleehen SS. A
double-blind, randomised, placebo-controlled of fish oil in
psoriasis. Lancet 1988;1:378–80.
Camp 1998
Camp RDR. Psoriasis. In: Champion RH, Burton
JL, Burns DA, Breathnach SM editor(s). Textbook of
Dermatology. 6th Edition. Oxford: Blackwell Science,
1998:1589–649.
Green 1992
Green C, Lakshmipathi T, Johnson BE, Ferguson J. A
compaarison of the efficacy and relapse rates of narrowband
UVB (TL-01) monotherapy vs. etretinate(re-TL-01) vs.
etretinate-PUVA (re-PUVA) in the treatment of psoriasis
patients. British Journal of Dermatology 1992;127:5–9.
Gupta 1989
Gupta AK, Ellis CN, Tellner DC, Anderson TF, Voorhees
JJ. Double-blind, placebo-controlled study to evaluate the
efficacy of fish oil and low-dose UVB in the treatment of
psoriasis. British Journal of Dermatology 1989;120:801–7.
Martin 1996
Martin BA, Chalmers RJG, Telfer NR. How great is the
risk of further psoriasis following a single episode of acute
guttate psoriasis?. Archives of Dermatology 1996;132:717.
Owen 2000
Owen CM, Chalmers RJG, O’Sullivan T, Griffiths CEM.
Owen CM, Chalmers RJG, O’Sullivan T, Griffiths CEM.
Cochrane Database of Systematic Reviews 2000, Issue 2.
Telfer 1992
Telfer NR, Chalmers RJG, Whale K, Colman G. The
role of streptococcal infection in the initiation of guttate
psoriasis. Archives of Dermatology 1992;128:39–42.
∗
Indicates the major publication for the study
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Grimminger 1993
Methods
Random allocation, (random list)
Participants
21 patients hospitalised for acute guttate psoriasis with at least 10% body surface area
involved (mean 25.7±20.4%, range 10-90%). Mean age 39.7 years (range 21-65). 1 dropout on day 1; 20 patients evaluated
Interventions
“Active” intervention: ten day course of twice daily intravenous infusions of n-3 fatty acidbased lipid emulsion (Omegavenös, Fresenius) providing 2.1g of eicosapentaenoic acid
and 2.1g of docosahexaenoic acid. Placebo: identical regimen using n-6 fatty acid-based
lipid emulsion (Lipovenös, Fresenius) consisting mainly of palmitic and oleic acids (<0.3%
eicosapentaenoic acid and arachidonic acid)
Outcomes
Reduction in disease severity scores over 10 days
Notes
Patients receiving systemic drug therapy of any kind excluded. Topical corticosteroid therapy stopped at least 5 days before entering study. Additional topical therapy limited to 0.
03% anthralin ointment
Risk of bias
Bias
Authors’ judgement
Support for judgement
Allocation concealment (selection bias)
Low risk
A - Adequate
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Melski 1977
This study of 1308 patients receiving PUVA therapy included over 120 patients with guttate psoriasis. Although
response to treatment in the guttate group was evaluated separately, the allocation of these patients to different
treatment groups was not stratified. A good response to therapy was observed in all groups, but guttate psoriasis
patients required fewer treatments to achieve clearance than those with chronic plaque disease or erythroderma
Interventions for guttate psoriasis (Review)
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DATA AND ANALYSES
Comparison 1. n-3 fatty acid infusion vs n-6 fatty acid infusion
No. of
studies
Outcome or subgroup title
1 Change in semi-quantitative
psoriasis severity score
1.1 Change in erythema
1.2 Change in infiltration
1.3 Change in desquamation
1
1
1
1
2 Change in patient-scored
subjective severity score
1
No. of
participants
Statistical method
Effect size
Mean Difference (IV, Fixed, 95% CI)
Subtotals only
20
20
20
Mean Difference (IV, Fixed, 95% CI)
Mean Difference (IV, Fixed, 95% CI)
Mean Difference (IV, Fixed, 95% CI)
20
Mean Difference (IV, Fixed, 95% CI)
-25.0 [-41.26, -8.74]
-36.0 [-62.87, -9.13]
-23.4 [-57.28, 10.
48]
-57.6 [-106.73, -8.
47]
Analysis 1.1. Comparison 1 n-3 fatty acid infusion vs n-6 fatty acid infusion, Outcome 1 Change in semiquantitative psoriasis severity score.
Review:
Interventions for guttate psoriasis
Comparison: 1 n-3 fatty acid infusion vs n-6 fatty acid infusion
Outcome: 1 Change in semi-quantitative psoriasis severity score
Study or subgroup
n-3 fatty acid
Mean
Difference
n-6 fatty acid
N
Mean(SD)
N
Mean(SD)
Grimminger 1993
9
-50 (18.9)
11
-25 (17.9)
Subtotal (95% CI)
9
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
1 Change in erythema
100.0 %
11
-25.00 [ -41.26, -8.74 ]
100.0 % -25.00 [ -41.26, -8.74 ]
Heterogeneity: not applicable
Test for overall effect: Z = 3.01 (P = 0.0026)
2 Change in infiltration
Grimminger 1993
9
Subtotal (95% CI)
9
-50.4 (37.8)
11
-14.4 (17.9)
100.0 %
11
-36.00 [ -62.87, -9.13 ]
100.0 % -36.00 [ -62.87, -9.13 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.63 (P = 0.0086)
3 Change in desquamation
Grimminger 1993
9
Subtotal (95% CI)
9
-45 (32.4)
100.0 %
11 -21.6 (44.77)
11
-23.40 [ -57.28, 10.48 ]
100.0 % -23.40 [ -57.28, 10.48 ]
-100
-50
n-3 FA (active)
0
50
100
n-6 FA (placebo)
(Continued . . . )
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Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
8
(. . .
Study or subgroup
n-3 fatty acid
Mean
Difference
n-6 fatty acid
N
Mean(SD)
N
Mean(SD)
Weight
IV,Fixed,95% CI
Continued)
Mean
Difference
IV,Fixed,95% CI
Heterogeneity: not applicable
Test for overall effect: Z = 1.35 (P = 0.18)
Test for subgroup differences: Chi2 = 0.53, df = 2 (P = 0.77), I2 =0.0%
-100
-50
0
n-3 FA (active)
50
100
n-6 FA (placebo)
Analysis 1.2. Comparison 1 n-3 fatty acid infusion vs n-6 fatty acid infusion, Outcome 2 Change in patientscored subjective severity score.
Review:
Interventions for guttate psoriasis
Comparison: 1 n-3 fatty acid infusion vs n-6 fatty acid infusion
Outcome: 2 Change in patient-scored subjective severity score
Study or subgroup
n-3 fatty acid
Mean
Difference
n-6 fatty acid
N
Mean(SD)
N
Mean(SD)
Grimminger 1993
9
-79.2 (70.2)
11
-21.6 (29.8)
Total (95% CI)
9
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
100.0 %
11
-57.60 [ -106.73, -8.47 ]
100.0 % -57.60 [ -106.73, -8.47 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.30 (P = 0.022)
Test for subgroup differences: Not applicable
-100
-50
n-3 FA (active)
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
0
50
100
n-6 FA (placebo)
9
WHAT’S NEW
Last assessed as up-to-date: 3 January 2000.
Date
Event
Description
3 October 2013
Amended
This review is going to be updated. We have written a published note to say that because the updating
team is completely new and the original review is very old, a new protocol and then a new review will
be written
HISTORY
Protocol first published: Issue 3, 1998
Review first published: Issue 2, 2000
Date
Event
Description
17 October 2008
Amended
Converted to new review format.
27 November 2003
New search has been performed
Minor update.
3 January 2000
New citation required and conclusions have changed
Substantive amendment
1 October 1999
Amended
Reformatted.
CONTRIBUTIONS OF AUTHORS
Teresa O’Sullivan performed the initial searches and draft of the review under the supervision of Robert Chalmers. The searches were
rechecked by Caroline Owen. The final review was synthesised by Caroline Owen and Robert Chalmers. Christopher Griffiths provided
comments and criticism.
DECLARATIONS OF INTEREST
Support from Boots Healthcare did not result in any conflict of interest.
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
10
SOURCES OF SUPPORT
Internal sources
• Section of Dermatology, University of Manchester, UK.
External sources
• Boots Healthcare, UK.
NOTES
This review is being updated by way of a new protocol and then a review because the updating team is completely new, and the original
review is very old.
INDEX TERMS
Medical Subject Headings (MeSH)
Psoriasis [∗ therapy]
MeSH check words
Humans
Interventions for guttate psoriasis (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
11

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