ARTICLE
Tacalcitol [1alpha-24 (R)-dihydroxycholecalciferol, abbreviated as 1,24(OH)2
D3] is an active vitamin D3 compound which is chemically
synthesized by the Teijin Institute for Biochemical Research, Tokyo, Japan
and tacalcitol ointment (2 mug/g tacalcitol) is an established treatment
method for psoriasis in Japan [1]. Recently, tacalcitol cream has also
been re-formulated, and the effectiveness of tacalcitol cream and ointment
on epidermal proliferation and differentiation has been shown to be equivalent
[2].
Controversy remains regarding the pathogenetic differences between psoriasis
vulgaris and seborrheic dermatitis. In addition, it is sometimes difficult
to distinguish accurately between psoriasis vulgaris and seborrheic dermatitis,
especially when eruptions are located on the face and/or scalp. In fact,
the medical terms "sebopsoriasis" or "seborrhiasis" do exist. The term
sebopsoriasis is not a universally accepted diagnosis but is the term
which can be applied to borderline dermatosis cases in which psoriasis
lesions are mixed with those of seborrheic dermatitis [3].
In the present study, we report on the clinical effectiveness of tacalcitol
cream on sebopsoriasis and seborrheic dermatitis of the face and/or scalp.
Case reports
Case 1
A 71-year-old female (a typical sebopsoriasis case).
Present illness. Scaly erythematous macules had emerged on her
lower extremities about 2 weeks before she visited our clinic. She also
noticed pityriatic scales on her face a couple of days before presentation.
She also felt a slightly itchy sensation. She had been prescribed several
drugs for the internal complications of NIDDM, hypertension, and hyperlipidemia
2 months before visiting our clinic.
Present status. On examination, she showed hyperkeratotic erythematous
macules on her lower extremities and back. She also showed erythematous
macules with fine scales on her forehead, cheeks, and eyebrows (Fig.
1A). She also complained of severe pityriatic scaling (dandruff)
(Fig. 2A). Scratch marks
due to itching were seen on her face, scalp, and lower extremities.
Histopathological findings. A skin biopsy of an erythematous
plaque on her right lower extremity was performed to make an accurate
diagnosis. The specimen showed mild hyperkeratosis, parakeratosis, acanthosis,
and elongated rete ridges of the epidermis with mild chronic inflammation.
Munro's microabscess was noted. These findings were consistent with those
of psoriasis vulgaris.
Treatment. The topical application of tacalcitol cream for the
face and scalp lesions twice daily was started. The eruptions of the face
and scalp began to improve 5 days after the treatment, and the lesions
cleared up completely
4 weeks after the treatment (Figs.
1B, 2B). The psoriatic eruptions of the lower extremities treated
with tacalcitol ointment also rapidly disappeared. After stopping the
topical application of tacalcitol cream no recurrence of scaly eruptions
was observed for 2 months.
Case 2
A 51-year-old male (a sebopsoriasis case).
Present illness. Scaly erythema and erythematous papules developed
on his knees, elbows, and ears a couple of years previously. Recently,
severe scaling on his scalp with slight itching occurred and, as a result,
he visited our clinic.
Treatment. Tacalcitol cream was applied twice daily on his face,
ears, and scalp. Steroid ointment (very strong class) was also applied
on his elbows and fingers twice daily. The facial erythema, especially
on the cheeks, and moderate scaling on his eyebrows almost completely
cleared up 4 weeks after the topical application of tacalcitol cream (Fig.
3A, B), but the thick scaly lesions on his scalp did not substantially
improve. The elbow lesions clearly improved 4 weeks after the topical
application of steroid ointment.
Case 3
A 71-year-old male (a sebopsoriasis or a true psoriasis case).
Present illness. A solitary pruritic scaly erythematous plaque
emerged on his left occipital a couple of months before presentation.
He had been treated with topical steroid lotion at a local dermatological
clinic, but he was not satisfied with the results, and thus he visited
our clinic.
Treatment. Tacalcitol cream was applied on his scalp twice daily.
A thick scaly plaque improved 1 week after the topical application of
tacalcitol cream (Fig. 4A, B).
However, moderate itchy discomfort continued. Therefore, steroid (betamethasone)
lotion was applied twice daily in combination with tacalcitol cream twice
daily. A clear clinical improvement was obtained, however, the symptoms
tended to recur after stopping the topical application of steroid lotion.
Case 4
A 50-year-old male (a seborrheic dermatitis case).
Present illness. He had suffered from slight pruritic eruptions
on his scalp, eyebrows, ears, back, and chest for about 10 years before
he visited our clinic. He had been treated with topical steroids but the
symptoms tended to recur easily. He was treated with tacalcitol cream
in combination with 2 anti-histamine tablets per day at our clinic. All
eruptions remarkably improved within 2 weeks. The diffuse erythematous
lesions on his face due to seborrheic dermatitis cleared up within 3 weeks
after starting the treatment (Fig.
5A, B). The eruptions did not recur for 2 months after he had
stopped the topical application of tacalcitol cream.
Discussion
Tacalcitol ointment (2 mug/g) has been widely used for psoriatic lesions
in Japan. In Europe, a comparative study on the efficacy and safety of
tacalcitol (4 mug/g) and calcipotriol (50 mug/g) has been performed and
it was concluded that both vitamin D3 compounds were useful
for chronic plaque psoriasis [4]. Because of a low concentration of active
vitamin D3 in the tacalcitol ointment, serious irritation after
the topical application for facial psoriatic eruptions has not been reported
so far. Tacalcitol ointment has been known to be especially effective
for psoriatic eruptions of the face.
Recently, tacalcitol cream (2 mug/g) has been re-formulated in Japan.
The clinical effectiveness of this cream has been shown to have the same
potency as that of tacalcitol ointment. Tacalcitol cream is a white odorless
emulsion ointment containing tacalcitol, and the cream base is composed
of 17 different chemical materials including tocopherol, squalene, white
petrolatum, macrogol, etc., which makes tacalcitol cream not sticky while
also allowing for good penetration through the skin [2]. Tacalcitol cream
is therefore considered to be highly useful for the treatment of psoriatic
eruptions on the face.
Clinically, psoriatic lesions of the face and/or scalp are sometimes
difficult to distinguish from those of seborrheic dermatitis. The pathological
findings of the two diseases are sometimes quite similar. It is therefore
of interest to investigate whether active vitamin D3 compound,
tacalcitol, is effective for the treatment of sebopsoriasis and seborrheic
dermatitis, also. Tacalcitol has been reported to have anti-inflammatory
effects in vivo [5, 6], which thus suggests its possible effectiveness
for the treatment of seborrheic dermatitis.
In a preliminary report, tacalcitol ointment was found to be effective
for the treatment of facial seborrheic dermatitis [7]. However, the application
of ointment to the face or the scalp is not practical because it is sticky
and shiny. As a result, another cream base containing tacalcitol was tested
to determine its effectiveness and safety for the treatment of facial
seborrheic dermatitis-like lesions.
Scaly erythema of sebopsoriasis or seborrheic
dermatitis lesions of the face and scalp could thus improve with tacalcitol
cream as soon as after 1 week of treatment. All cases tested for the facial
lesions showed a remarkable improvement within 4 weeks. These findings
seem to be unique since tacalcitol ointment usually improves the typical
psoriatic lesions of the face after a couple of months. Another impressive
point in the present study is that no relapse was observed for at least
2 months after the withdrawal of the tacalcitol cream. This is a significant
finding since recurrence usually occurs within 1 month after the withdrawal
of steroid cream or lotion for the treatment of seborrheic dermatitis.
In addition, the tacalcitol cream did not cause irritation or any adverse
effects such as telangiectasia or perioral dermatitis which often occurs
after the longterm use of steroids.
It should be pointed out that sebopsoriatic thick scaly lesions of the
scalp are difficult to treat with tacalcitol cream effectively. The moderate
itchy discomfort of the scalp lesion did not substantially improve in
spite of the fact that the thick scales did decrease. In such cases, other
such topical modalities as steroid lotion should be combined with tacalcitol
cream.
Tacalcitol cream was thus found to be clearly effective for the treatment
of sebopsoriasis or even seborrheic dermatitis lesions of the face and/or
scalp, although it is difficult for sebopsoriatic lesions (or even psoriatic
lesions) of the scalp with thick scales to improve with tacalcitol cream
only. Seborrheic dermatitis of the trunk is also found to be fairly responsive
to tacalcitol cream. In general, tacalcitol ointment or cream is more
effective for facial psoriatic lesions as compared to those on the trunk
because of the efficient absorption or penetration of tacalcitol through
facial skin. In cases of seborrheic dermatitis, however, its effectiveness
for lesions of the face and the trunk seemed to be equivalent. No serious
adverse effects, such as irritation due to the tacalcitol cream were observed.
A critical evaluation of the long term use of tacalcitol cream for seborrheic
dermatitis should be performed in the future.
Article accepted on 26/7/00
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