Charles E. Crutchfield III, MMB, MD
University of Minnesota
Minneapolis, Minnesota, USA
Correspondence should be addressed to: Charles E. Crutchfield III, MMB, MD.
Keywords: Dermatohistopathology, Zinc Pyrithione, Psoriasis, clobetasol, treatment.
Psoriasis is a chronic inflammatory skin disease that affects approximately 3% of the world's population. Topical therapeutic approaches have included tars, salicylic acid preparations, vitamin D derivatives, ultraviolet light and corticosteroids. We report here the dermatohistopathologic correlation of the normalization of human skin, observed clinically, in psoriatic lesions treated with a novel topical liquid spray preparation containing clobetasol propionate (0.05% w/v), emollient, detergent, alcohol, and zinc pyrithione. This topical liquid preparation may be more effective than cream or ointment preparations containing corticosteroids of equal strength.
It has recently been demonstrated, clinically, that human psoriatic skin lesions can successfully be treated with a novel topical liquid formulation containing clobetasol propionate (0.05% w/v), emollient, detergent, alcohol, and zinc pyrithione (1-5). In this report, we present the dermatohistopathologic evaluation of these clinical findings.
MATERIALS AND METHODS
The patient presented here treated a psoriatic plaque on his abdomen, twice per day, with a spray containing the active ingredient clobetasol propionate, 0.05% (in a vehicle containing isopropyl myristate, alcohol and detergent). The volume of each treatment application was approximately 0.5 cc. The treatment period was 42 days (August-September, 1996). Clinical clearing occurring at day 21. The tissue was processed by standard histologic methods and stained with hematoxylin and eosin for the following dermatohistopathologic evaluation.
This section shows the standard cutaneous changes associated with a psoriatic lesion. There is hyperkeratosis with parakeratosis and neutrophils within the stratum corneum. The granular layer is absent. The epidermis is markedly acanthotic with elongation of the rete ridges and a prominence of dermal papillae with dilated vasculature. Dermal papillae rise high and the epidermal regions over the dermal papillae are thinned. Neutrophils are also exiting the dermal papillae in a process often termed "squirting papillae". The dermis contains perivascular lymphocytes and neutrophils. (See figure 1)
There is a reduction in the hyperkeratosis of the stratum corneum, decrease in the amounts of parakeratosis and neutrophils within the stratum corneum. The granular layer is re-emerging. The vascular dilatation within the dermal papillae is greatly diminished. The epidermal acanthosis is also markedly reduced. The dermis still contains perivascular infiltrates of lymphocytes and neutrophils, but the amounts are diminished. (See figure 2)
The abnormalities identified in the previous sections have vanished. This section essentially demonstrates normal human skin: normal basket-weave stratum corneum, normal granular layer, normal epidermis and normal dermis. (See figure 3)
DISCUSSION AND CONCLUSIONS
This dermatohistopathologic evaluation correlates well with the clinical changes seen in a plaque of psoriasis treated with a spray containing the active ingredient clobetasol propionate (0.05%) in a vehicle containing isopropyl myristate, alcohol, zinc pyrithione (0.02%) and detergent. Essentially, a standard psoriatic skin lesion transformed into a picture of normal human skin.
Steroids have long been used in the treatment of inflammatory skin disorders, but I report here the use of a high potency steroid in a liquid vehicle . I believe that the vehicle plays a major role in the effectiveness of this preparation, especially the detergent component. I am unsure of the effect of zinc pyrithione to treat psoriasis. It has been well documented to treat seborrheic dermatitis (1), but there have been no studies that suggest its sole effectiveness in the treatment of psoriasis. In fact, zinc pyrithione does not have FDA approval for the treatment of psoriasis. Please note that references (2-4) listed in this article were published before the discovery that the preparation evaluated in those articles was discovered to contain clobetasol propionate (6). In several psoriatic patients using the formulation without the clobetasol propionate, the results were initially promising, but, unfortunately, long term follow-up of these patients failed to demonstrate any conclusive effectiveness of the preparation. Perhaps the zinc pyrithione acts to augment the effectiveness of the clobetasol, but does not have any primary effectiveness in the treatment of psoriasis. A double blind, vehicle controlled study is needed to demonstrate the effectiveness of zinc pyrithione (without steroid) in the treatment of psoriasis.
Topical potent corticosteroids in a novel liquid vehicle containing detergent, alcohol, zinc pyrithione, and emollient appears to be a very effective treatment for psoriasis. This preparation seems to be more effective than equal strength corticosteroids based in cream or ointment vehicles. Long term safety issues along with the elucidation of cellular mechanism(s) of action of this preparation on psoriatic lesions, need to be evaluated with additional research efforts.
We wish to thank Drs. Valda Kaye and Mark Wilke for the histologic processing of the specimens.
- Marks R, Pearse AD, Walker AP. The effects of a shampoo containing zinc pyrithione on control of dandruff. Br J Dermatol 1985;112:415-22.
- Crutchfield C, Lewis E, and Zelickson B: The effective use of topical zinc pyrithione in the treatment of psoriasis. Journal of Geriatric Dermatology. 5(1):21-24,Jan/Feb 1997.
- Crutchfield C, Lewis E, and Zelickson B: The highly effective use of topical zinc pyrithione in the treatment of psoriasis: a case report. The Dermatology Online Journal. 3(1):3. (Internet Address: http://matrix.ucdavis.edu/DOJvol3num1/zinc/zinc.html)
- Crutchfield C, Lewis E, and Zelickson B: The effective and safe use of topical zinc pyrithione in the treatment of psoriasis: a report of 10 cases. American Academy of Dermatology Clinical Research Symposium Presentation, 55th Annual Meeting, San Francisco, CA, March 22, 1997.
- Crutchfield C, Lewis E, and Zelickson B: The successful, safe, and highly effective use of topical zinc pyrithione in the treatment of psoriasis: a report of 10 cases. Journal of Investigative Dermatology. 108(4):656,April 1997.
- P. Dechnik: FDA cites dangers of hidden steroid in banning of Skin-Cap. Dermatology Times. November 1997, supplement page 27.
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