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    Clinical Trial Results:
    Efficacy and Safety of LEO 43204 in Field Treatment of Actinic Keratosis on Balding Scalp including 12-month follow-up Part 1: 3-day treatment period including an 8-week follow-up period Part 2: extended 12-month follow-up period A phase 3, multi-centre, randomised, parallel group, double-blind, vehicle controlled trial

    Summary
    EudraCT number
    2015-002451-10
    Trial protocol
    GB  
    Global end of trial date
    06 Sep 2017

    Results information
    Results version number
    v1(current)
    This version publication date
    20 Dec 2018
    First version publication date
    20 Dec 2018
    Other versions

    Trial information

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    Trial identification
    Sponsor protocol code
    LP0084-1195
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT02547363
    WHO universal trial number (UTN)
    -
    Sponsors
    Sponsor organisation name
    LEO Pharma A/S
    Sponsor organisation address
    Industriparken 55, Ballerup, Denmark, 2750
    Public contact
    Clinical Disclosure Specialist, LEO Pharma A/S, +45 44945888, disclosure@leo-pharma.com
    Scientific contact
    Clinical Disclosure Specialist, LEO Pharma A/S, +45 44945888, disclosure@leo-pharma.com
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    27 Feb 2018
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    06 Sep 2017
    Global end of trial reached?
    Yes
    Global end of trial date
    06 Sep 2017
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    To confirm the efficacy of LEO 43204 gel (0.037% for scalp) in actinic keratosis (AK) when applied topically once daily for 3 consecutive days as field treatment
    Protection of trial subjects
    This clinical trial was conducted in accordance with the revision current at the start of the trial of the World Medical Association’s Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects. All subjects received written and verbal information concerning the clinical trial. This information emphasised that participation in the clinical trial was voluntary and that the subject could withdraw from the clinical trial at any time and for any reason. All subjects were given an opportunity to ask questions and were given sufficient time to consider before consenting
    Background therapy
    -
    Evidence for comparator
    -
    Actual start date of recruitment
    20 Nov 2015
    Long term follow-up planned
    Yes
    Long term follow-up rationale
    Safety
    Long term follow-up duration
    12 Months
    Independent data monitoring committee (IDMC) involvement?
    No
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    United Kingdom: 27
    Country: Number of subjects enrolled
    France: 20
    Country: Number of subjects enrolled
    Canada: 106
    Country: Number of subjects enrolled
    United States: 160
    Worldwide total number of subjects
    313
    EEA total number of subjects
    47
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    73
    From 65 to 84 years
    225
    85 years and over
    15

    Subject disposition

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    Recruitment
    Recruitment details
    Subjects were followed for 8 weeks following the first application of investigational medicinal product (IMP) at Day 1 (3-day treatment period including an 8-week follow-up period) and for an additional 12 months following Week 8 (extended 12-month follow-up period).

    Pre-assignment
    Screening details
    373 subjects were enrolled, 57 were screening failures, and 316 subjects were randomised. Only 313 of the randomised subjects were treated with investigational medicinal product (IMP), the number of subjects treated is reflected as the number of subjects started in the first period.

    Period 1
    Period 1 title
    3-day Treatment and 8-week Follow-up
    Is this the baseline period?
    Yes
    Allocation method
    Randomised - controlled
    Blinding used
    Double blind
    Roles blinded
    Subject, Investigator

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up
    Arm description
    Treatment once daily with LEO 43204 0.037% gel for 3 consecutive days applied on the scalp.
    Arm type
    Experimental

    Investigational medicinal product name
    LEO 43204 gel
    Investigational medicinal product code
    Other name
    Ingenol disoxate
    Pharmaceutical forms
    Gel
    Routes of administration
    Topical use
    Dosage and administration details
    Ingenol disoxate 0.037% gel applied on the scalp once-daily for 3 consecutive days.

    Arm title
    Vehicle Gel - Treatment Period Including Follow-up
    Arm description
    Treatment once daily with vehicle gel for 3 consecutive days applied on the scalp.
    Arm type
    Placebo

    Investigational medicinal product name
    LEO 43204 Vehicle Gel
    Investigational medicinal product code
    Other name
    Placebo
    Pharmaceutical forms
    Gel
    Routes of administration
    Topical use
    Dosage and administration details
    Vehicle gel applied on the scalp once-daily for 3 consecutive days.

    Number of subjects in period 1
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up Vehicle Gel - Treatment Period Including Follow-up
    Started
    209
    104
    Completed
    207
    94
    Not completed
    2
    10
         Other
    1
    1
         Adverse event, non-fatal
    -
    1
         Consent withdrawn by subject
    -
    7
         Lost to follow-up
    1
    1
    Period 2
    Period 2 title
    12-month Follow-up
    Is this the baseline period?
    No
    Allocation method
    Randomised - controlled
    Blinding used
    Double blind
    Roles blinded
    Subject, Investigator

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    LEO 43204 0.037% Gel - Extended Follow-up
    Arm description
    Treatment once daily with LEO 43204 0.037% gel for 3 consecutive days applied on the scalp.
    Arm type
    Experimental

    Investigational medicinal product name
    LEO 43204 gel
    Investigational medicinal product code
    Other name
    Ingenol disoxate
    Pharmaceutical forms
    Gel
    Routes of administration
    Topical use
    Dosage and administration details
    Ingenol disoxate 0.037% gel applied on the scalp once-daily for 3 consecutive days.

    Arm title
    Vehicle Gel - Extended Follow-up
    Arm description
    Treatment once daily with vehicle gel for 3 consecutive days applied on the scalp.
    Arm type
    Placebo

    Investigational medicinal product name
    LEO 43204 Vehicle Gel
    Investigational medicinal product code
    Other name
    Placebo
    Pharmaceutical forms
    Gel
    Routes of administration
    Topical use
    Dosage and administration details
    Vehicle gel applied on the scalp once-daily for 3 consecutive days.

    Number of subjects in period 2 [1]
    LEO 43204 0.037% Gel - Extended Follow-up Vehicle Gel - Extended Follow-up
    Started
    204
    86
    Completed
    194
    81
    Not completed
    10
    5
         Other
    1
    -
         Lack of efficacy
    1
    1
         Consent withdrawn by subject
    4
    3
         Lost to follow-up
    4
    1
    Notes
    [1] - The number of subjects starting the period is not consistent with the number completing the preceding period. It is expected the number of subjects starting the subsequent period will be the same as the number completing the preceding period.
    Justification: Of the 301 subjects who completed the 3-day treatment and 8-week Follow-up period, 3 subjects in the ingenol disoxate gel group and 8 subjects in the vehicle group were not included in the 12-month Follow-up because they withdrew after Week 8.

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up
    Reporting group description
    Treatment once daily with LEO 43204 0.037% gel for 3 consecutive days applied on the scalp.

    Reporting group title
    Vehicle Gel - Treatment Period Including Follow-up
    Reporting group description
    Treatment once daily with vehicle gel for 3 consecutive days applied on the scalp.

    Reporting group values
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up Vehicle Gel - Treatment Period Including Follow-up Total
    Number of subjects
    209 104 313
    Age categorical
    Units: Subjects
        Adults (18-64 years)
    45 28 73
        From 65-84 years
    155 70 225
        85 years and over
    9 6 15
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    70.9 ± 9.1 69.9 ± 9.3 -
    Gender categorical
    Units: Subjects
        Female
    1 0 1
        Male
    208 104 312

    End points

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    End points reporting groups
    Reporting group title
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up
    Reporting group description
    Treatment once daily with LEO 43204 0.037% gel for 3 consecutive days applied on the scalp.

    Reporting group title
    Vehicle Gel - Treatment Period Including Follow-up
    Reporting group description
    Treatment once daily with vehicle gel for 3 consecutive days applied on the scalp.
    Reporting group title
    LEO 43204 0.037% Gel - Extended Follow-up
    Reporting group description
    Treatment once daily with LEO 43204 0.037% gel for 3 consecutive days applied on the scalp.

    Reporting group title
    Vehicle Gel - Extended Follow-up
    Reporting group description
    Treatment once daily with vehicle gel for 3 consecutive days applied on the scalp.

    Primary: Complete Clearance of Actinic Keratosis (AK)

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    End point title
    Complete Clearance of Actinic Keratosis (AK)
    End point description
    The number of clinically visible AKs identified in the treatment area was recorded at Day 1 (Baseline), Week 4, and Week 8. Complete clearance was defined as no clinically visible AKs in the treatment area. The table shows percentage of subjects with complete clearance.
    End point type
    Primary
    End point timeframe
    At Week 8
    End point values
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects analysed
    209
    104
    Units: percentage of subjects
    number (confidence interval 95%)
        Yes
    25.8 (20.4 to 32.2)
    0.0 (0.0 to 3.6)
    Statistical analysis title
    Complete clearance of AK at Week 8
    Comparison groups
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up v Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects included in analysis
    313
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    < 0.001
    Method
    Fisher exact test
    Confidence interval

    Secondary: Partial Clearance

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    End point title
    Partial Clearance
    End point description
    The number of clinically visible Actinic keratosis lesions (AKs) identified in the treatment area was recorded at Day 1, Weeks 4 and Week 8. Partial clearance was defined as at least 75% reduction from baseline in the number of clinically visible AKs in the treatment area. The table shows percentage of subjects with complete clearance.
    End point type
    Secondary
    End point timeframe
    At Week 8
    End point values
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects analysed
    209
    104
    Units: percentage of subjects
    number (confidence interval 95%)
        Yes
    58.9 (52.1 to 65.3)
    1.0 (0.2 to 5.2)
    Statistical analysis title
    Statistical analysis 1
    Statistical analysis description
    The p-values for secondary endpoints have been corrected by the Holm-Bonferroni method to account for multiplicity. The prespecified multiplicity adjustment by the Holm-Bonferroni method requires the ordering of the p-values for the secondary endpoints by size.
    Comparison groups
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up v Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects included in analysis
    313
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    < 0.001
    Method
    Mantel-Haenszel
    Parameter type
    Ratio of clearance rates
    Point estimate
    62.59
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    8.68
         upper limit
    451.08

    Secondary: Partial Clearance

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    End point title
    Partial Clearance
    End point description
    The number of clinically visible Actinic keratosis lesions (AKs) identified in the treatment area was recorded at Day 1, Weeks 4 and Week 8. Partial clearance was defined as at least 75% reduction from baseline in the number of clinically visible AKs in the treatment area. The table shows percentage of subjects with complete clearance.
    End point type
    Secondary
    End point timeframe
    At Week 4
    End point values
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects analysed
    209
    104
    Units: percentage of subjects
    number (confidence interval 95%)
        Yes
    57.4 (50.6 to 63.9)
    1.0 (0.2 to 5.2)
    Statistical analysis title
    Statistical analysis 1
    Statistical analysis description
    The p-values for secondary endpoints have been corrected by the Holm-Bonferroni method to account for multiplicity. The prespecified multiplicity adjustment by the Holm-Bonferroni method requires the ordering of the p-values for the secondary endpoints by size.
    Comparison groups
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up v Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects included in analysis
    313
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    < 0.001 [1]
    Method
    Mantel-Haenszel
    Parameter type
    Ratio of clearance rates
    Point estimate
    59.21
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    8.44
         upper limit
    415.35
    Notes
    [1] - Nominal p-value

    Secondary: Percent Reduction in AK Count in the Treatment Area Compared to Baseline

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    End point title
    Percent Reduction in AK Count in the Treatment Area Compared to Baseline
    End point description
    The percent reduction at Week 8 from baseline was analysed using a negative binomial regression for the AK count at Week 8 with treatment group and pooled sites as factors and baseline count as offset variable. The table presents adjusted mean percent reduction at Week 8 from baseline.
    End point type
    Secondary
    End point timeframe
    At Week 8
    End point values
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects analysed
    209
    104
    Units: percentage of reduction
        arithmetic mean (confidence interval 95%)
    72.3 (69.1 to 75.2)
    -2.0 (-16.0 to 10.3)
    Statistical analysis title
    Statistical analysis
    Statistical analysis description
    The p-values for secondary endpoints have been corrected by the Holm-Bonferroni method to account for multiplicity. The prespecified multiplicity adjustment by the Holm-Bonferroni method requires the ordering of the p-values for the secondary endpoints by size.
    Comparison groups
    LEO 43204 0.037% Gel - Treatment Period Including Follow-up v Vehicle Gel - Treatment Period Including Follow-up
    Number of subjects included in analysis
    313
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    < 0.001
    Method
    Mantel-Haenszel
    Parameter type
    Week 8 AK count ratio
    Point estimate
    0.27
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    0.23
         upper limit
    0.32

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    Treatment period including follow-up (from Day 1 to Week 8) and extended follow-up (from Week 8 up to Month 14)
    Adverse event reporting additional description
    Adverse events presented in the table are investigator-reported terms. Adverse events of special interest within system organ class (SOC) Neoplasm benign, malignant and unspecified (incl cysts and polyps), were adjudicated by an Independent Adjudication Committee based on central biopsy review.
    Assessment type
    Non-systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    18.1
    Reporting groups
    Reporting group title
    LEO 43204 0.037% Gel - Treatment Period including Follow-up
    Reporting group description
    Treatment once daily for 3 consecutive days with LEO 43204 0.037% gel

    Reporting group title
    Vehicle Gel - Treatment Period Including Follow-up
    Reporting group description
    Treatment once daily for 3 days with vehicle gel

    Reporting group title
    LEO 43204 0.037% Gel - Extended Follow-up
    Reporting group description
    Treatment once daily for 3 consecutive days LEO 43204 0.037% gel

    Reporting group title
    Vehicle Gel - Extended Follow-up
    Reporting group description
    Treatment once daily for 3 days Vehicle gel

    Serious adverse events
    LEO 43204 0.037% Gel - Treatment Period including Follow-up Vehicle Gel - Treatment Period Including Follow-up LEO 43204 0.037% Gel - Extended Follow-up Vehicle Gel - Extended Follow-up
    Total subjects affected by serious adverse events
         subjects affected / exposed
    4 / 209 (1.91%)
    2 / 104 (1.92%)
    1 / 204 (0.49%)
    0 / 86 (0.00%)
         number of deaths (all causes)
    0
    0
    0
    0
         number of deaths resulting from adverse events
    0
    0
    0
    0
    Neoplasms benign, malignant and unspecified (incl cysts and polyps)
    Malignant melanoma
         subjects affected / exposed
    0 / 209 (0.00%)
    0 / 104 (0.00%)
    1 / 204 (0.49%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 0
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Neoplasm of appendix
         subjects affected / exposed
    1 / 209 (0.48%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Pancreatic carcinoma
         subjects affected / exposed
    0 / 209 (0.00%)
    1 / 104 (0.96%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Cardiac disorders
    Acute myocardial infarction
         subjects affected / exposed
    1 / 209 (0.48%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Pericarditis
         subjects affected / exposed
    1 / 209 (0.48%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Sinus node dysfunction
         subjects affected / exposed
    0 / 209 (0.00%)
    1 / 104 (0.96%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Psychiatric disorders
    Mental status changes
         subjects affected / exposed
    1 / 209 (0.48%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Infections and infestations
    Appendicitis perforated
         subjects affected / exposed
    1 / 209 (0.48%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
    0 / 0
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    0 / 0
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 2%
    Non-serious adverse events
    LEO 43204 0.037% Gel - Treatment Period including Follow-up Vehicle Gel - Treatment Period Including Follow-up LEO 43204 0.037% Gel - Extended Follow-up Vehicle Gel - Extended Follow-up
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    134 / 209 (64.11%)
    3 / 104 (2.88%)
    18 / 204 (8.82%)
    12 / 86 (13.95%)
    Neoplasms benign, malignant and unspecified (incl cysts and polyps)
    Squamous cell carcinoma of skin
         subjects affected / exposed
    0 / 209 (0.00%)
    0 / 104 (0.00%)
    5 / 204 (2.45%)
    1 / 86 (1.16%)
         occurrences all number
    0
    0
    5
    1
    Nervous system disorders
    Headache
         subjects affected / exposed
    21 / 209 (10.05%)
    2 / 104 (1.92%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    21
    2
    0
    0
    Eye disorders
    Periorbital oedema
         subjects affected / exposed
    14 / 209 (6.70%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    14
    0
    0
    0
    General disorders and administration site conditions
    Application site pain
         subjects affected / exposed
    127 / 209 (60.77%)
    3 / 104 (2.88%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    127
    3
    0
    0
    Application site pruritus
         subjects affected / exposed
    64 / 209 (30.62%)
    2 / 104 (1.92%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    64
    2
    0
    0
    Application site discomfort
         subjects affected / exposed
    6 / 209 (2.87%)
    2 / 104 (1.92%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    6
    2
    0
    0
    Application site injury
         subjects affected / exposed
    8 / 209 (3.83%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    8
    0
    0
    0
    Face oedema
         subjects affected / exposed
    5 / 209 (2.39%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    5
    0
    0
    0
    Application site scar
         subjects affected / exposed
    1 / 209 (0.48%)
    1 / 104 (0.96%)
    10 / 204 (4.90%)
    7 / 86 (8.14%)
         occurrences all number
    1
    1
    10
    7
    Psychiatric disorders
    Insomnia
         subjects affected / exposed
    5 / 209 (2.39%)
    0 / 104 (0.00%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    5
    0
    0
    0
    Skin and subcutaneous tissue disorders
    Post inflammatory pigmentation change
         subjects affected / exposed
    0 / 209 (0.00%)
    0 / 104 (0.00%)
    5 / 204 (2.45%)
    5 / 86 (5.81%)
         occurrences all number
    0
    0
    5
    5
    Infections and infestations
    Nasopharyngitis
         subjects affected / exposed
    6 / 209 (2.87%)
    1 / 104 (0.96%)
    0 / 204 (0.00%)
    0 / 86 (0.00%)
         occurrences all number
    6
    1
    0
    0

    More information

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    04 Mar 2016
    The amendment clarified which medications were allowed and prohibited during the extended follow-up period: lesiondirected laser treatment was added to the allowed medications, and Actikerall, even as lesiondirected treatment, and laser treatment as field treatment were prohibited. The remaining changes in the amendment were either administrative changes or matters that needed further clarification.

    Interruptions (globally)

    Were there any global interruptions to the trial? No

    Limitations and caveats

    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported
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