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PAPERS: Darren M Ashcroft, Alain Li Wan Po, Hywel C Williams, and Christopher E M Griffiths Systematic review of comparative efficacy and tolerability of calcipotriol in treating chronic plaque psoriasis BMJ 2000; 320: 963-967 [Abstract] [Full text]

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Lack of knowledge about latest treatment protocol for chronic plaque psoriasis?

Damien Cullington   (10 April 2000)

The limits of confidence

Rustam Al-Shahi   (14 April 2000)

Lack of knowledge about latest treatment protocol for chronic plaque psoriasis? 10 April 2000
Damien Cullington, 3rd Year Medical Student Liverpool University Send response to journal: Re: Lack of knowledge about latest treatment protocol for chronic plaque psoriasis?	Dear Sir, My colleage and I have recently completed a GP based audit which studied the treatments offered to patients suffering with mild-to-moderate chronic plaque psoriasis. From our results we found that only 21.4% (3 out of 14) patients who have been prescribed a corticosteroid are using a vitamin D3 analogue as part of a combinant therapy regimen for mild-to-moderate chronic plaque psoriasis. The remainder are receiving corticosteroids only. The reason for not receiving vitamin D3 analogues was not due to any irritant effects suffered and hence withdrawal of treatment. Apart from the accompanying risks of topical steroid use, corticosteroids still remain the most common first-line therapy for psoriasis and on average 55% of psoriatic patients receive potent topical steroids(1) The combinant use of vitamin D3 analogues and corticosteroids are recommended as first-line treatments of mild-to-moderate plaque psoriasis and this fact is well supported by numerous trials.(2+3+4) Although our study is limited by its small sample size and we cannot conclude that these results reflect general trends or that they are statistically significant, we suggest that it is necessary to investigate the reasons as to why this combinant treatment has not been implemented - is it a cost issue? Patients should be reviewed in order to decide to whom combination therapy should be offered. Perhaps topical corticosteroids should only be considered in patients with a poor therapeutic response to calcipotriol?(3) If a corticosteroid is used as a first-line treatment of choice for chronic plaque psoriasis, consideration should be given to prescribing it together with a vitamin D3 analogue, since it has been shown that combination therapy is more efficacious than the use of corticosteroids alone.(2) We postulate from the findings of our small project that although this treatment protocol is recommended there is a lack of awareness of these findings amongst doctors which needs to be addressed to provide optimal care for their patients. Damien Cullington (3rd Year MBChB Liverpool University) Anita Jhamatt (3rd Year MBChB Liverpool University) 1. Kownaki S. Team care in psoraisis. UPDATE Jan 1999 (Suppl. 1) : 3-5. 2. Kragballe K et al. Calcipotriol cream with or without concurrent topical corticosteroid in psoriasis : tolerability and efficacy. British Journal of Dermatology 1998; 139 : 649-654. 3. Ruzicka T & Lorenz B. Comparison of calcipotriol monotherapy and a combination of calcipotriol and betamethasone valerate after 2 weeks treatment with calcipotriol in the topical therapy of psoriasis vulgaris : a multicentre, double-blind, randomised study. British Journal of Dermatology 1998; 138 : 254-258. 4. Lebwohl M et al. A multi-centre trial of calcipotriol ointment and halobetasol ointment with either agent alone for the treatment of psoriasis. Journal of the American Academy of Dermatology 1996; 35: 268- 269.
The limits of confidence 14 April 2000
Rustam Al-Shahi, MRC Clinical Training Fellow Department of Clinical Neurosciences, University of Edinburgh Send response to journal: Re: The limits of confidence	EDITOR - Whilst the importance of confidence intervals was spelt out long ago [1], we still need to dot the i's and cross the t's of the interval. Confidence intervals demonstrate how precisely a sample estimates its parent population, based on sample size, the variability of the characteristic being studied and the degree of confidence required (usually 95%). Because the choice of the interval size is arbitrary, the use of the term confidence limits is discouraged [2]. However, the pictorial representation of a confidence interval in a forest plot, using a horizontal line with vertical lines marking its lower and upper values [3], gives the same misleading impression of 'limits'. Although this is a minor (95% CI pedantic to reasonable) point, the illustration of confidence intervals in forest plots in the BMJ should not add a subliminal impression of a limit to their already successful representation of uncertainty, especially not for the overall pooled effect. Rustam Al-Shahi, MRC clinical training fellow Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU [1] Langman MJS. Towards estimation and confidence intervals. BMJ 1986; 292: 716. [2] Altman DG, Machin D, Bryant TN, Gardner MJ (eds). Statistics with confidence. 2nd edn. BMJ Books, 2000. [3] Ashcroft DM, Li Wan Po A, Williams HC, Griffiths CEM. Systematic review of comparative efficacy and tolerability of calcipotriol in treating chronic plaque psoriasis. BMJ 2000; 320: 963-967. (8 April).