Cumulative UVA Dose Research Articles

Bath-PUVA still represents a valuable treatment option for the subsets of psoriatic patients who are not eligible to or rejecting systemic treatments and are not responsive to NB-UVB phototherapy.

Photochemotherapy with bathwater delivery of psoralens plus UVA exposures (bath-PUVA) is mainly used for those psoriatic patients who are not responsive to narrowband (NB)-UVB phototherapy and oral-PUVA therapy and belong to two categories (1) patients with psoriasis without systemic comorbidities who do not need long-term continuous treatment and (2) patients who have contraindications to immunosuppressive drugs and oral-PUVA or refuse systemic drugs, including oral ingestion of psoralens, for personal reasons. However, it is not known how many patients belong to the second group and how much bath-PUVA is effective and safe for them. We have reviewed the treatment results of a cohort of 120 patients with clinical indication to bath-PUVA for the above-mentioned reasons between 2010 and 2019. These patients were selected among 2640 patients with moderate and severe psoriasis who were treated in our department in the same time interval. Ninety-six patients completed at least one treatment cycle with bath-PUVA. A per-protocol analysis showed that average number of treatment sessions was 21.3 ± 9.0 and the cumulative UVA dose was 80.4 ± 60.0J/cm2 . The average PASI scores decreased from 20.8 ± 7.9 to 5.1 ± 5.4 (p < .01). Sixty-seven (69.7%) patients achieved at least a 75% improvement (PASI75 ) and, of them, 38 (39.6%) had an improvement greater than 90% (PASI90 ). Adverse effects were mild and transitory. These findings demonstrate that bath-PUVA is still a valuable treatment option for a high number of patients who reject systemic treatments or have contraindications to systemic immune-modifying drugs and have had a limited or no improvement with NB-UVB phototherapy.

Risk of cutaneous carcinogenesis with phototherapy in Indian subpopulation: A 10‐year analysis and a review of literature

Phototherapy is an extremely effective and established therapeutic modality in a variety of dermatological disorders. However, there has been a constant concern with respect to its long-term usage as some of the studies have identified the risk of cutaneous malignancy associated with phototherapy. The carcinogenic potential of PUVA has been demonstrated in most US studies; however, the studies done on Asian and Arabian-African population have not corroborated similar findings, thus suggesting that the darker skin may confer protection against the development of cutaneous malignancy following phototherapy. The main aim of the present study was to assess the safety of phototherapy (bath PUVA and NBUVB) in Indian population (Fitzpatrick skin types IV and V) with respect to its carcinogenic potential and to determine the maximum cumulative dose that our patients could tolerate without developing any untoward complications such as cutaneous malignancy. All patients who received phototherapy between January 2006 and October 2016 were enrolled in the study. Details such as cumulative dose, number of phototherapy sessions received, indication for phototherapy, adverse effects such as pigmentary changes, new growths on the skin surface following the therapeutic sessions were entered in a predesigned proforma. This ambispective study had 1300 patients who had received phototherapy over a period of 10 years. A total of 929 patients had received PUVA, and the remaining 371 patients had received NBUVB for various dermatological indications. The average follow-up period for PUVA was 3 years and 6.5 years for NBUVB. The maximum cumulative dose of UVA and UVB that could be safely administered in our patients was 2085 J/cm2 and 1985 mJ/cm2, respectively. None of our patients developed any features of cutaneous malignancy during their follow-up. Both bath-PUVA and NBUVB are safe and efficacious in treating patients of darker skin types (IV and V). The risk of developing cutaneous malignancy is negligible in this subset of patients. However, more studies need to be done on the Asian population to substantiate the same.

Opuntiol Prevents Photoaging of Mouse Skin via Blocking Inflammatory Responses and Collagen Degradation.

In the present study, we investigated the potential of opuntiol, isolated from Opuntia ficus-indica, against UVA radiation-mediated inflammation and skin photoaging in experimental animals. The skin-shaved experimental mouse was subjected to UVA exposure at the dosage of 10 J/cm2 per day for ten consecutive days (cumulative UVA dose: 100 J/cm2). Opuntiol (50 mg/kg b.wt.) was topically applied one hour before each UVA exposure. UVA (100 J/cm2) exposure induces epidermal hyperplasia and collagen disarrangement which leads to the photoaging-associated molecular changes in the mouse skin. Opuntiol pretreatment prevented UVA-linked clinical macroscopic skin lesions and histological changes in the mouse skin. Further, opuntiol prevents UVA-linked dermal collagen fiber loss in the mouse skin. Short-term UVA radiation (100 J/cm2) activates MAPKs through AP-1 and NF-κB p65 transcriptional pathways and subsequently induces the expression of inflammatory proteins and matrix-degrading proteinases in the mouse skin. Interestingly, opuntiol pretreatment inhibited UVA-induced activation of iNOS, VEGF, TNF-α, and COX-2 proteins and consequent activation of MMP-2, MMP-9, and MMP-12 in the mouse skin. Moreover, opuntiol was found to prevent collagen I and III breakdown in UVA radiation-exposed mouse skin. Thus, opuntiol protects mouse skin from UVA radiation-associated photoaging responses through inhibiting inflammatory responses, MAPK activation, and degradation of matrix collagen molecules.

Evaluation of Low-Dose, Low-Frequency Oral Psoralen–UV-A Treatment With or Without Maintenance on Early-Stage Mycosis Fungoides

Psoralen-UV-A (PUVA) photochemotherapy is standard first-line treatment for skin-limited, early-stage mycosis fungoides capable of producing high initial complete response (CR) rates. However, much remains unknown about PUVA's therapeutic mechanisms, optimal duration and frequency of treatment, dose escalation, or use as maintenance therapy. To evaluate low-dose, low-frequency PUVA, and whether maintenance treatment extends disease-free remission in patients with mycosis fungoides. This prospective randomized clinical trial with defined PUVA dosing regimen was carried out in 5 centers (Graz, Vienna, Hietzing, Innsbruck, and Salzburg) across Austria. Patients with stage IA to IIA mycosis fungoides (n = 27) were enrolled in the study beginning March 13, 2013, with the last patient enrolled March 21, 2016. These patients were treated with oral 8-methoxypsoralen followed by UV-A exposure 2 times per week for 12 to 24 weeks until CR. Patients with CR were randomized to PUVA maintenance for 9 months (14 total exposures) or no maintenance. The study was conducted from April 27, 2012, to July 27, 2018. Data analysis of the primary end point was of the intention-to-treat population, and the secondary end point analysis was of the evaluable population. Efficacy of the PUVA regimen was determined by the rate of CR as defined by a modified severity-weighted assessment tool (mSWAT) score reduction to 0. Levels of proinflammatory molecules in serum and histologic features and percentage of clonal T cells in skin were assessed to search for biomarkers of clinical response. In 27 patients with mycosis fungoides, 19 (70%) were male with mean (range) age 61 (30-80) years. At baseline, patients with CR had a mean (range) mSWAT score of 18.6 (1-66) compared with 16.8 (3-46) in patients with partial response. The 12- to 24-week PUVA induction regimen reduced the mSWAT score in all patients and led to CR in 19 (70%) of 27 patients and a low mean cumulative UV-A dose of 78.5 J/cm2. The subsequent standardized 9-month PUVA maintenance phase prolonged median (range) disease-free remission from 4 (1-20) months to 15 (1-54) months (P = .02). High density of histologic infiltrate and high percentage of clonal TCR sequences in skin biopsy specimens at baseline were inversely associated with therapeutic response. No severe adverse effects were seen during the PUVA induction or maintenance phase. This proof-of-concept study identifies potential biomarkers for therapeutic response to PUVA in mycosis fungoides; it also demonstrates that low-dose, low-frequency PUVA appears to be highly effective, and maintenance treatment may extend disease-free remission. ClinicalTrials.gov identifier: NCT01686594.

Cumulative Solar UVA–UVB Exposure Increases Heat Shock Protein (HSP) 72 on Peripheral Blood Cutaneous Lymphocytes Antigen (CLA)+T Lymphocytes in Outdoor Workers

Solar UVA–UVB radiation is responsible for development and continuity of life in the earth, but it can endanger human health. Heat shock proteins (HSP) play an essential role in the homeostasis of the living cell when cells exposed to environmental stress. Several investigators had proved increased Hsp72 expression on keratinocytes caused by UVA–UVB exposure, but the effects in peripheral blood Cutaneous Lymphocytes Antigen (CLA)+T lymphocytes, the cells that have a significant role in skin immunity, still have not been proven. To investigate the effect of cumulative solar UVA–UVB exposure on Hsp72 expression on peripheral blood CLA+T lymphocytes in outdoor workers. This cohort study had been conducted involving 70 male subjects consisting of 37 caddies of a golf course and 33 indoor workers (one was drop out) in Surabaya, on July to September, 20–45 years old, skin phototype IV/V. Doses of solar UVA–UVB in first four weeks and eight weeks of the study were measured by Viospor® blue line II dosimeter. Hsp72 expression on the peripheral blood CLA+T lymphocytes were measured at baseline, four weeks, and eight weeks by flow cytometry. The average dose of solar UVA–UVB received over eight weeks by caddies was 12450.5±3948.8 J/m2 whereas that obtained by the indoor workers was 1794.0±1518.5 J/m2 (p = 0.0001). The Cumulative high dose of solar UVA–UVB exposure induced the increased of Hsp72 on peripheral blood CLA+T lymphocytes (p = 0.0001). The Cumulative high dose of solar UVA–UVB exposure in subjects with high outdoor activities increases Hsp72 expression on peripheral blood CLA+T lymphocytes.

Treatment of Early Folliculotropic Mycosis Fungoides with Special Focus on Psoralen plus Ultraviolet A.

Data on the treatment of early folliculotropic mycosis fungoides, a recently defined clinicopathological subgroup of folliculotropic mycosis fungoides with an indolent course, is limited. Treatment outcomes were studied in a retrospective cohort of 47 adults with early folliculotropic mycosis fungoides, with a focus on psoralen plus ultraviolet A (PUVA) monotherapy, including dosimetric data, and the findings were compared with data for PUVA in 18 adults with early-classic mycosis fungoides. PUVA was given to 27 patients with early folliculotropic mycosis fungoides: 70% achieved complete response and 26% partial response. Significantly more treatments were needed to achieve complete response in stage IB compared with stage IA. There was no significant difference in the complete response rate from classic plaque-stage disease, although the early folliculotropic mycosis fungoides group required more treatments to achieve complete response, and a higher cumulative dose of UVA. Thus, PUVA is an effective treatment for early folliculotropic mycosis fungoides. Its complete response rate might be equal to early-classic mycosis fungoides; however, a longer induction phase is needed to achieve complete response.

Solar photocatalytic disinfection of E. coli and bacteriophages MS2, ΦX174 and PR772 using TiO2, ZnO and ruthenium based complexes in a continuous flow system

The performance of photocatalytic treatment processes were assessed using different photocatalysts against E. coli and bacteriophages MS2, ΦX174 and PR772, in a recirculating continuous flow compound parabolic collector system under real sunlight conditions. Suspended TiO2 and ZnO nanoparticle powders and Tris(2,2′-bipyridyl)dichlororuthenium(II) hexahydrate in solution were tested separately, as well as in combination, using E. coli. For a 3-log reduction of E. coli in distilled water, inactivation rates in terms of cumulative dose were in the order Ru(bpy)3Cl2>(TiO2 & Ru(bpy)3Cl2)>(ZnO & Ru(bpy)3Cl2)>ZnO>TiO2>photolysis. Reactivation of E. coli was observed following all trials despite the detection limit being reached, although the reactivated colonies were observed to be under stress and much slower growing when compared to original colonies. Treatment with Ru(bpy)3Cl2 was also compared against standard photolysis of bacteriophages MS2, ΦX174 and PR772 with the order of photolytic inactivation for a 3-log reduction in terms of cumulative UV-A dose being ΦX174>PR772>MS2. However, MS2 was found to be the most susceptible bacteriophage to treatment with Ru(bpy)3Cl2, with complete removal of the phage observed within the first 15min of exposure. Ru(bpy)3Cl2 also significantly improved inactivation rates for PR772 and ΦX174.

Dead Sea ultraviolet climatotherapy for children with atopic dermatitis.

Atopic dermatitis (AD) is a common, chronic, and relapsing inflammatory skin disorder. Moderate to severe cases represent an extremely disabling disease, for both children and their parents. Dead Sea climatotherapy (DSC), recognized as a natural treatment for patients with skin diseases, takes advantage of the selectively scattered ultraviolet irradiation (UV) present at the lowest terrestrial site on the earth. To investigate the impact on short-term results of DSC in moderate to severe AD children from the Czech Republic treated 4 weeks at the Deutsches Medizinisches Zentrum (DMZ), Israel, and to correlate their results to the cumulative UVA and UVB irradiation doses received during treatment. Seventy-two patients aged <19 years were divided into three groups and treated in March 2014, October 2014, and March 2015 with gradually increasing sun exposure during 28 consecutive days. Daily and cumulative exposure doses of UVB and UVA were calculated through patients' recorded sun exposure logs. The SCORing Atopic Dermatitis (SCORAD) index was recorded immediately after DSC and 3 months later by the same dermatologist. Good clinical results were observed in all groups, with overall improvement in SCORAD reaching 87.5 ± 13.4% and 71.3 ± 21.3% immediately after DSC and 3 months later, respectively. No side effects were observed during the treatments. Higher cumulative exposure times correlated with better results and enhanced remission. Dead Sea climatotherapy represents a valuable option for the treatment of AD in children. Medically controlled and prescribed sun exposure seems to directly and positively influence the results obtained.

Treatment of stage Ia and Ib mycosis fungoides with psoralen UVA monotherapy: an observational study in tertiary hospitals in the Canary Islands

Mycosis fungoides (MF) is the most common form of primary cutaneous Tcell lymphoma. Psoralen combined with ultraviolet A (PUVA) is a first-line treatment for early-stage disease. This study was conducted to assess the clinical effectiveness of and tolerance to PUVA monotherapy in MF. We retrospectively reviewed the files of patients who received PUVA for stage I disease. The study included 31 patients, of whom 32% presented with stage Ia and 67% with stage Ib disease, and 68% presented with patch and 32% with plaque disease. All patients received treatment three times per week. Complete response (CR) was achieved in 71% of patients. The median cumulative dose of UVA at CR was 211.7J/cm(2) . There was a significant difference in median cumulative dose at CR between patients with plaque and patch disease, respectively, but not between patients with stage Ia and Ib disease. Median disease-free survival (DFS) was 230weeks. Patients with patch disease achieved longer DFS than those with plaque disease (P=0.004), although DFS was similar in stage Ia and Ib patients. Of the patients who received maintenance therapy, 58% relapsed. Univariate analysis showed patch disease to be a predictive factor for CR, but no predictors of relapse were identified. A total of 71% of patients developed clinical adverse reactions. Psoralen with UVA is a safe and effective treatment for early-stage MF. Patch disease responds more favorably than plaque disease and is associated with a longer period of DFS. Maintenance treatment does not appear to reduce recurrence. Current evidence suggests that the proposed revision to the classification of MF, which takes into account the extent and type of disease, more accurately predicts response to PUVA.

Targeted photochemotherapy in alopecia areata

Alopecia areata (AA) is a common cause of localized non-scarring alopecia. Usage of targeted UVA after the topical application of 8-methoxypsoralen (8-MOP) is one of the rising treatment modalities for AA. Our aim was to assess the efficacy and safety of topical 8-MOP plus targeted UVA phototherapy in the treatment of patchy AA. Seven patchy AA patients were treated by topical 8-MOP application to the lesions followed by UVA irradiation 3 times a week, with 15 to 24 sessions in total. At the end of the treatment all patients were evaluated for response on a four-point scale (0 = no hair, 1 = white vellus hair, 2 = regrowth cosmetically acceptable for the patient, 3 = complete hair growth). The mean cumulative UVA dose was from 7.5 to 39.6 J/cm(2) . For all 7 patients, average response score was calculated as 2, which means cosmetically acceptable regrowth. Targeted UVA phototherapy combined with topical 8-MOP may be an effective and safe alternative treatment protocol for patchy AA, which should be kept in mind in order to choose the best for the patient, especially for patients incompatible with other treatments that are systemic and invasive.

Phototherapy for pityriasis lichenoides: our experience

Pityriasis lichenoides is a benign disease that includes a continuous spectrum with two polar ends: pityriasis lichenoides et varioliformis acuta (PLEVA) and pityriasis lichenoides chronica (PLC). Although its benign and self-limited character, treatment is required, both for itch relief and for cosmetic issues. The present study is a retrospective analysis of 13 patients (11 PLC and 2 PLEVA) treated in our institution with psoralen plus ultraviolet A (PUVA) or ultraviolet A combined with ultraviolet B (UVA/UVB) during the period 1998–2011. In the PUVA group, complete response was achieved in five patients and partial response in two. Total cumulative UVA dose was 84.4 J/cm2. One patient quit therapy without therapeutic response. In the UVA/UVB group, complete response was achieved in two patients and partial response in an equal number of patients. One patient did not reach a significant improvement. Total cumulative doses were: 26.1 J/cm2 for UVA and 3.62 J/cm2 for UVB. There were no acute side effects in either therapeutic group. In the present study, PUVA phototherapy was preferred for patients with more widespread or long-evolving disease, while UVA/UVB was selected for patients who presented more recent disease or contraindications for PUVA therapy. Regardless of the absence of clinical guidelines, both therapeutic options proved to be successful, ascertaining phototherapy as an effective and safe option for pityriasis lichenoides patients.

Retrospective long‐term follow‐up in patients with chronic palmoplantar dermatoses after good response to bath PUVA therapy

Numerous studies have confirmed the short-term effectiveness of 8-methoxypsoralen bath PUVA therapy in patients with chronic palmoplantar dermatoses; however, little is known about long-term results. In this retrospective study we examined the long-term results in 79 patients (mean age: 48 years) with chronic palmoplantar dermatoses who were treated with bath PUVA three times a week over an 8-year period. A good clinical response (a reduction of more than 50% of the skin lesions) occurred after a mean of 23 treatments and a mean cumulative UVA dose of 39 J/cm(2) in 51 patients (65%). In 2007 a questionnaire was sent to these 51 patients to assess the long-term outcome. With bath PUVA treatment, the best results were found in patients with hyperkeratotic eczema (17/22; 77% good clinical response) followed by patients with palmoplantar psoriasis (26/41; 63%) and patients with dyshidrotic eczema (8/16; 50%). Thirty-four patients (67%) answered the questionnaire after a mean follow-up interval of 4.3 years (10-87 months). Among these patients, 36% reported an improved course of disease after PUVA therapy with reduced frequency and/or intensity of the skin rash, and 29% of patients reported continued complete clearance. 79% of our patients reported a long-term reduction in the use of topical corticosteroids during the follow-up period (mean: 4.3 years). In addition, 67% of patients reported a lasting improvement in quality of life. These data show that bath PUVA may have a long-term, beneficial influence on the course of disease in a majority of patients with recalcitrant chronic palmoplantar dermatoses.

Efficacy and safety of bexarotene combined with psoralen/ultraviolet A light (PUVA) compared to PUVA treatment alone in stage IB-IIa mycosis fungoides (MF): Final results from EORTC cutaneous lymphoma task force (CLTF) phase III clinical trial 21011.

8076 Background: Skin-directed treatment with methoxsalen (PUVA) is the current treatment standard in stage IB-IIA MF. A combination of PUVA and bexarotene might be of additional clinical benefit for MF stage I/II patients (pts). Methods: EORTC 21011 was a randomised, open label phase III study comparing combined bexarotene and PUVA versus PUVA alone in pts with stage IB and IIA MF. Study primary endpoint was response (complete clinical + partial response, CCR+PR) rate; secondary endpoints: cumulative dose of UVA and number of PUVA sessions necessary to achieve a CCR, duration of CCR, time to relapse, safety and percentage of drop-outs. Results: The study recruited stage IB/IIA MF pts and was prematurely closed due to low accrual after 93/145 required pts (65%) were randomized; 45 to PUVA, 48 to PUVA+bexarotene. Median number of PUVA weeks were 12 (1-17) in PUVA vs. 10.5 (1-16) in combination arm. Total UVA doses were 107J/cm2 (1.4-489.9) in PUVA vs. 101.7J/cm2 (0.2-529.9) in combination arm. Few grade 3-4 toxicities were observed in both arms (liver enzyme elevation, neutropenia, anemia, increased cholesterol, photosensitivity, pruritus, rash, hypertriglyceridemia). Best overall response (CCR/PR) rate was 71.1% (33/45) for PUVA alone and 77.1% (37/48) for combination arm (p-value=0.57). The median of duration of response was 9.6 for PUVA vs 5.8 months for combination arm (p value=0.33). CCR was seen in 25 pts, 10 in PUVA (CCR 24%) and 15 in combination therapy (CCR 33%) (pvalue=0.45). Similarily, a lower UVA dose was required to achieve a CCR in the combination arm (median of 55.8 J/cm2) compared to the PUVA arm (median of 117.58 J/cm2) (p value=0.5). Conclusions: No significant difference in response rate was observed in this study. There was a trend towards fewer PUVA sessions and lower UVA dose to achieve CCR in the PUVA/bexarotene combination arm (median of 27.5 vs. 22,p-value = 0.11) but this did not achieve statistical significance due to insufficient power. The safety profile was acceptable, as there were only few grade 3-4 toxicities observed in both arms.

Efficacy of topical PUVA soaks for palmoplantar dermatoses: an audit

With a lack of evidence base for individual topical PUVA protocols, treatment is presently based on the consensus of current practice. This audit was designed to investigate the effectiveness of topical PUVA for palmoplantar dermatoses. Phototherapy notes were reviewed on all patients who received hand and/or foot PUVA 2002-2007 in the Northern Health and Social Care Trust (NHSCT), Northern Ireland. Thirty patients met the inclusion criteria for the study. The mean number of treatments, maximum single UVA dose, and cumulative dose, were 18.4, 4.2 J/cm2, and 48.3 J/cm2, respectively. A positive response to treatment occurred in 51.3% of patients, which fell short of the 70% standard set. In a multivariate logistic regression analysis, number of treatments (P=0.04) and maximum single UVA dose (P=0.03) were the only variables associated with positive treatment outcome. The response was not influenced significantly by skin type, concurrent topical treatments, or cumulative UVA dose. Limitations to the study: Small patient numbers may have prevented the statistical significance of individual variables. UV dose increments should be clearly defined to avoid excess caution at the expense of an adequate patient response, and a minimum of 20 treatments administered to all patients, if tolerated.

Is the efficacy of psoralen plus ultraviolet A therapy for vitiligo enhanced by concurrent topical calcipotriol? A placebo-controlled double-blind study

Background Encouraging results of previous uncontrolled trials suggest that calcipotriol may potentiate the efficacy of psoralen plus ultraviolet (UV) A (PUVA) therapy in patients with vitiligo. Objectives We performed a placebo-controlled double-blind study to investigate whether the effectiveness of PUVA treatment could be enhanced by combination with topical calcipotriol in the treatment of vitiligo. Methods Thirty-five patients with generalized vitiligo enrolled in the study. Symmetrical lesions of similar dimensions and with no spontaneous repigmentation on arms, legs or trunk were selected as reference lesions. In this randomized left-right comparison study, calcipotriol 0·05 mg g−1 cream or placebo was applied to the reference lesions 1 h before PUVA treatment (oral 8-methoxypsoralen and conventional UVA units) twice weekly. Patients were examined at weekly intervals. The mean number of sessions and the cumulative UVA dosage for initial and complete repigmentation were calculated. Results Twenty-seven patients (nine women, 18 men; mean ± SEM age 29·8 ± 13·5 years) were evaluated. The mean ± SEM cumulative UVA dose and number of UVA exposures for initial repigmentation were 52·52 ± 6·10 J cm−2 and 9·33 ± 0·65 on the calcipotriol side, and 78·20 ± 7·88 J cm−2 and 12·00 ± 0·81 on the placebo side, respectively (P < 0·001). For complete repigmentation, respective values were 232·79 ± 14·97 J cm−2 and 27·40 ± 1·47 on the calcipotriol side and 259·93 ± 13·71 J cm−2and 30·07 ± 1·34 on the placebo side (P = 0·001). Treatment with calcipotriol and PUVA resulted in significantly higher percentages of repigmentation for both initial (81%) and complete pigmentation (63%), compared with placebo and PUVA (7% and 15%, respectively). Conclusions Our results have shown that concurrent topical calcipotriol potentiates the efficacy of PUVA in the treatment of vitiligo, and that this combination achieves earlier pigmentation with a lower total UVA dosage.

A comparative study of different treatment frequencies of psoralen and ultraviolet A in psoriatic patients with darker skin types (randomized‐controlled study)

Photochemotherapy psoralen and ultraviolet A (PUVA) is a viable option for treatment of psoriasis. However, concerns about its side effects have raised the need to change current PUVA protocols. The aim of this study is to determine whether reducing the treatment frequency of PUVA to twice/week instead of three times/week would affect the efficacy of PUVA therapy. The study included 20 psoriatic patients, randomized into two groups, 10 patients in each group. The first group received two weekly sessions, the second group received three. The study lasted until complete clearance or for 12 weeks (endpoint). Psoriasis area and severity index (PASI) score was done prior to therapy, at mid therapy and at end of therapy (PASI final). No significant different in PASI final and in the percentage of reduction of PASI score between both groups (P value >0.05) was found. However, a significant difference in the total number of sessions and the total cumulative UVA doses between both groups was found (P value <0.001). Our study suggests reducing PUVA frequency and the cumulative UVA dose does not compromise the efficacy of PUVA, but it may improve its benefit/risk ratio. RESTRICTIONS: Few number of cases.

Mittel-Dosis-UVA-1- und lokale PUVA-Therapie beim dyshidrosiformen Handekzem - eine prospektive randomisierte Studie

Diese Studie zielte darauf ab, zwei unterschiedliche Behandlungsregimes für das dyshidrosiforme Handekzem zu vergleichen, die mitteldosierte UVA-1 Bestrahlung und die lokale Creme-PUVA-Therapie (topisches Psoralen und UVA). 15 Patienten wurden in einer prospektiven, randomisierten (rechte vs. linke Hand) Studie über fünf Wochen 3 × pro Woche bestrahlt. Die mit der 0,001 %igen 8-Methoxypsoralen-Creme (Creme-PUVA) behandelte Hand wurde mit wöchentlich ansteigenden UVA-Dosen bestrahlt (kumulative UVA-Dosis 17,4 J/cm²). Bei der mit Mittel-Dosis-UVA-1 behandelten Hand wurde die Dosis von 40 J/cm² beibehalten (kumulative UVA-1-Dosis 600 J/cm²). Um die therapeutischen Effekte zu vergleichen, wurde ein Schweregradscore, der sog. DASI (Dyshidrotic Eczema Area and Severity Index) verwandt. Von 15 eingeschlossenen Patienten gingen 11 in die Endauswertung ein (1 × non Compliance, 1 × bakterielle Sekundärinfektion, 1 × Exazerbation, 1 × nicht studienbedingte Erkrankung). Nach insgesamt 15 Behandlungen führte sowohl die Creme-PUVA-Therapie (p = 0,0498; n = 11), als auch die UVA-1-Therapie (p = 0,0039; n = 11) verglichen mit den erhobenen Befunden vor Behandlungsbeginn zu einer signifikanten Besserung des Handekzem-Schweregrades (Wilcoxon-Test für verbundene Stichproben). Bei einem p-Wert von p = 0,307 konnte kein Unterschied zwischen beiden Therapieformen bzgl. ihrer Wirksamkeit nachgewiesen werden (U-Test von Mann und Whitney). Jede der beiden Therapieformen für sich genommen war wirksam (Reduktion des DASI um mehr als die Hälfte) und nebenwirkungsarm. Der therapeutische Effekt war mit geringeren kumulativen Dosen zu erzielen als bislang publiziert.

Skin cancers or premalignant lesions occur in half of high-dose PUVA patients.

Although treatment of psoriasis with psoralen and ultraviolet A (PUVA) is associated with a long-term risk of development of cutaneous squamous cell carcinoma (SCC), the role of PUVA alone is not established, as many patients in reported series had also received treatment with other carcinogens, such as superficial X-rays or arsenic. We have recalled and examined 54 of the 63 patients still alive who have had PUVA treatment in our department, and who have been exposed to a cumulative UVA dose greater than 2000J/cm2. None of the patients had been treated with superficial X-rays or arsenicals. Ten patients (19%) had developed SCC, and 25 (46%) had histologically atypical squamous keratoses arising at body sites similar to the carcinomas. The patients with SCC were significantly older at the start of PUVA treatment than those with keratoses alone. None of the 13% of patients without PUVA lentigines had keratoses or SCCs. These results show that high-dose PUVA treatment in the U.K., even when given alone, can frequently result in the development of SCC. Further malignancies are to be expected with continued follow-up of the patients with squamous keratoses. Absence of PUVA lentigines may be a useful indicator of a lower risk of PUVA malignancy.

Efficacy of 8-methoxypsoralen vs. 5-methoxypsoralen plus ultraviolet A therapy in patients with mycosis fungoides

Psoralen plus ultraviolet (UV) A (PUVA) is the standard treatment for early stage mycosis fungoides (MF). When 8-methoxypsoralen (8-MOP) is used in PUVA therapy, it often produces intolerance reactions such as nausea, vomiting and headache. To investigate whether 5-methoxypsoralen (5-MOP) is a safe and effective alternative to 8-MOP in PUVA therapy for MF. A retrospective database search and chart review was done to identify patients with MF who received PUVA with either 5-MOP or 8-MOP as initial monotherapy at our institution. Between 1990 and 2004, 14 patients [seven men and seven women; mean age 70 years, range 51-82; National Cancer Institute disease stages IA (n = 6) and IB (n = 8)] received 5-MOP, and 24 patients [21 men and three women; mean age 58 years, range 28-89; disease stages IA (n = 11), IB (n = 12) and IIB (n = 1)] received 8-MOP. Twelve of 14 patients (86%) in the 5-MOP group and 22 of 24 (92%) in the 8-MOP group had a complete response to PUVA. These two subgroups of complete responders did not differ significantly in terms of PUVA therapy duration, number of treatments or cumulative UVA dose. They also did not differ significantly in terms of relapse-free rate [8% (one of 12) vs. 23% (five of 22)] or time to relapse [17 months (range 4-31) vs. 14 months (range 4-33)]. Moreover, PUVA maintenance therapy with either 5-MOP or 8-MOP in a subset of patients [26% (nine of 34)] did not affect long-term relapse-free status either. 5-MOP and 8-MOP have comparable therapeutic efficacy when used in PUVA therapy for MF.

Bath‐water PUVA Therapy with 8‐Methoxypsoralen in Mycosis Fungoides

PUVA therapy is widely used for early stage mycosis fungoides. While the efficacy of PUVA with oral 8-methoxypsoralen (8-MOP) is well documented, the use of its topical variation, bath-water PUVA therapy with 8-MOP has not been studied. The purpose of this study was to assess the effect of 8-MOP bath-water PUVA therapy in adult patients with early stage mycosis fungoides. We retrospectively evaluated the outcomes of bath-water delivery of 8-MOP (1 mg l(-1)) in 16 patients with early stage mycosis fungoides. In all patients complete response was achieved after a mean duration of 63 days requiring 29 treatments and a mean cumulative UVA dose of 33 J cm(-2). The time to relapse after complete clinical clearance was 45.6 (+/-9.2) weeks. In comparison, oral PUVA therapy with 8-MOP resulted in complete response after 64.5 days (25.8 treatments) with a mean relapse-free period of 30 (+/-3.5) weeks. We conclude that bath-water PUVA therapy with 8-MOP is a valuable photo-therapeutic alternative, which should be considered for patients in whom systemic psoralen cannot be used.