Interventions for chronic palmoplantar pustulosis: abridged Cochrane systematic review and GRADE assessments

Sep 22, 2020The British journal of dermatology

Treatments for long-term palm and sole pustule skin condition: summary of evidence and quality ratings

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Abstract

A total of 1663 participants were analyzed across 37 randomized controlled trials for treatments of palmoplantar pustulosis (PPP).

Topical vitamin D derivative may be significantly more effective than placebo for achieving skin clearance.
Etanercept showed little or no difference compared to placebo in achieving clearance of PPP.
Ustekinumab is likely less effective than placebo in reducing the severity of PPP.
Guselkumab and secukinumab are probably more effective than placebo in reducing disease severity.
Both guselkumab and secukinumab may lead to a higher occurrence of serious side effects compared to placebo.

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BACKGROUND: Palmoplantar pustulosis (PPP) is a chronic inflammatory disease in which sterile and relapsing pustules appear on the palms and soles.

OBJECTIVES: To assess the effects of interventions for chronic PPP to induce and maintain complete remission.

METHODS: We searched for randomized controlled trials (RCTs), including people with PPP or chronic palmoplantar pustular psoriasis, in the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and eight trials registers up to July 2020. Study selection, data extraction and risk-of-bias assessment were carried out independently by two review authors. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method.

RESULTS: We included 37 RCTs (1663 participants, 76% women, mean age 50 years). Mean treatment duration was 11 weeks. Topical vitamin D derivative may be more effective than placebo in achieving clearance [risk ratio (RR) 7·83, 95% confidence interval (CI) 1·85-33·12; low-certainty evidence from two trials]. Concerning biological therapies, there was little or no difference between etanercept and placebo in achieving clearance (low-certainty evidence from one trial), ustekinumab is less effective than placebo in reducing severity (low-certainty evidence from one trial), and guselkumab (RR 2·88, 95% CI 1·24-6·69) and secukinumab (RR 1·55, 95% CI 1·02-2·35) are probably better in reducing disease severity (moderate-certainty evidence from two and one trial(s), respectively) but may cause more serious adverse events than placebo.

CONCLUSIONS: Evidence is lacking for or against major chronic PPP treatments. Risk of bias and imprecision limit our confidence in the results.

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Interventions for chronic palmoplantar pustulosis: abridged Cochrane systematic review and GRADE assessments

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