Bath Psoralen Research Articles

Hypertrophic Lichen Planus in a 38-year-old Filipino Male: A Case Report

Abstract Hypertrophic lichen planus (HLP) is a papulosquamous eruption presenting with extremely pruritic hyperkeratotic flat-topped papules, plaques, and nodules. This is a case of 38-year-old male who presented with a 2-month history of generalized erythematous-to-hyperpigmented papules, patches, and plaques topped with white-to-gray oyster shell-like scales on a background of hyperpigmented macules and patches. There was no involvement of the conjunctival, otic, oral, and genital mucosae, and palmar and plantar aspects of the hands and feet. Dermoscopy showed reticular pearly white structures corresponding to the Wickham striae, comedo-like openings, blue-gray dots, brownish-black dots, and scales. Histopathologic examination revealed marked compact hyperkeratosis, wedge-shaped hypergranulosis, irregular saw-toothed epidermal acanthosis, scattered dyskeratotic keratinocytes, and superficial perivascular lichenoid infiltrate of lymphocytes, histiocytes, and melanophages. The patient was managed as a case of HLP. He was started on methotrexate 10 mg per week, bath psoralen photochemotherapy (PUVA) three times a week, betamethasone valerate 1mg/g cream twice a day for 2 weeks alternating with tacrolimus 0.1% ointment twice a day for another 2 weeks, 10% lactic acid, emollients, and sunscreen. After 6 months of treatment, there was almost 80% improvement of lesions and relief of pruritus.

Bath psoralen plus ultraviolet-A photochemotherapy for chronic graft-versus-host disease: a retrospective cohort study.

Chronic graft-versus-host disease is a severe complication of allogeneic stem cell and bone marrow transplantation. First-line immunosuppressive agents, such as steroids, are used to prevent this disease; however, they have multiple side effects. Therefore, bath psoralen plus ultraviolet-A (PUVA) is an alternative second-line treatment. This study aimed to evaluate the clinical efficacy of bath PUVA for managing chronic graft-versus-host disease. This retrospective, case-control study included 14 patients with extensive cutaneous chronic graft-versus-host disease, resistant to systemic corticosteroid, treated with bath PUVA. Major and partial responses were defined as clinical improvements of >70% and 50-70%, respectively. We analyzed the graft-versus-host disease clinical presentation and timing after allogeneic stem cell and bone marrow transplantation, bath PUVA doses, background diseases, additional treatments, and adverse effects. We observed eight major (three lichenoid and five sclerodermatoid) and six partial (three lichenoid and three sclerodermatoid) responses after a mean of 28 treatment sessions. After 6 to 25 months, four of the eight patients with sclerodermatoid lesions and all those with lichenoid lesions experienced relapse but responded to additional treatment cycles. Bath PUVA is well-tolerated and effective for extensive cutaneous chronic graft-versus-host disease. It allows rapid tapering of adjuvant immunosuppressants; however, most patients require prolonged maintenance phototherapy.

Folliculotropic mycosis fungoides successfully treated with bath psoralen plus ultraviolet a therapy

Folliculotropic mycosis fungoides successfully treated with bath psoralen plus ultraviolet a therapy

Bath Psoralen Plus UVA Therapy Suppresses Keratinocyte-Derived Chemokines in Pathogenetically Relevant Cells

Psoriasis is a chronic inflammatory proliferative skin disease involving various types of chemokines regulating immune cell migration, localization, and activation. Bath psoralen plus UVA (PUVA) treatment is an established phototherapy for psoriasis, but its effects on chemokine levels remain unknown. We investigated the levels of 22 serum chemokines in 20 patients with psoriasis first treated with bath PUVA therapy between 2007 and 2011 in a single center and analyzed the associations between the chemokines and disease severity (PASI) before and after therapy to investigate the mechanisms of action of bath PUVA therapy. Before bath PUVA therapy, the PASI scores correlated with the serum levels of CCL17 (r = 0.581), CCL18 (r = 0.462), CCL19 (r = 0.477), and CXCL16 (r = 0.524). After bath PUVA, the serum levels of CCL17, CCL22, CXCL1, and CXCL9 were significantly decreased. Heatmap clustering and network analysis based on statistically significant Spearman correlations among the chemokines showed distinctive changes in the chemokine signature. Our findings revealed that the levels of several chemokines correlated with the disease state of psoriasis. Furthermore, bath PUVA therapy reduced the secretion of keratinocyte-derived chemokines that induce the migration of immune cells important for psoriasis pathogenesis, partly revealing the mechanism of the therapeutic activity.

Indoor salt water baths followed by artificial ultraviolet B light for chronic plaque psoriasis.

Indoor salt water baths followed by artificial ultraviolet B light for chronic plaque psoriasis.

SOAP PUVA.

Psoralen plus ultraviolet A (PUVA) photochemotherapy combines the use of psoralen and long-wave ultraviolet A (UVA) radiation. The phototherapeutic effects of PUVA result from photochemical reactions. PUVA therapy can be administered in various methods such as conventional UV chambers, psoralen with sunlight as source of UV light PUVASOL, bath PUVA, bath suit PUVA, soak PUVA, and turban PUVA. The advantage of using topical psoralen is that it avoids the adverse effects associated with the oral PUVA therapy and is being increasingly used in the treatment of psoriasis. However, it is known to cause increased phototoxicity, and in conditions like vitiligo, the spotty repigmentation is not cosmetically acceptable. Psoralen bath plus UVA therapy is known as bath PUVA therapy. Bath PUVA treatment for psoriasis was first reported by Fischer and Alsins in 1976. Bath PUVA is administered by mixing 37.5 mL of 1% 8-methoxypsoralen in 100 Lof water to obtain a concentration of 3.75 mg/L.[1] In bath suit PUVA, bathing suit of flannel material (stitched to suit the patient) is dipped in this solution for 5 min and worn for 15 min with a raincoat over it to prevent evaporation of the solution, and the patient is then immediately exposed to UVA in a whole-body phototherapy chamber. Bath PUVA needs plenty of water. Bath tub is not easily available and bath suit needs special suit, and treatment is cumbersome. We planned to modify the therapy by mixing psoralen with cleansing lotion and coined it as SOAP PUVA. The choice is due to the solubility factor as 8-MOP being insoluble in water. We reported a novel method of delivering 8-MOP uniformly all over the skin within a short time and on subsequent exposure to UV light. Because8-MOP was not soluble in water, we tried to dissolve it in commercially available moisturizing lotion (cetaphil) and synthetic detergent (cetaphil cleansing lotion). As it dissolved well in cleansing lotion, we decided to use it for our study [Figure 1]. As the method was new, we initially tried to standardize the procedure and determine the minimal pigmentation dose (MPD). The project was done in a single healthy subject with no existing dermatological disease requiring phototherapy. We started by using 1:100 dilution of methoxsalen that was prepared by mixing 0.1 mL of methoxsalen with 9.9 mL of cleansing lotion. The mixture was applied over the back [Figure 2]. The paste was left over for 5 min after which it was wiped with water-soaked gauze. The template cloth was worn along with goggles to protect the eyes. The area was exposed to UVA light (0–3J) with 0.5-J increments. The plan was to observe for MPD after 48 h and delayed pigmentation upto 7 days. No erythema and pigmentation was observed upto 7 days. We increased the concentration to 1:80, and the same procedure was repeated with no erythema or pigmentation. The concentration was increased to 1:60 and the same procedure was repeated. Erythema was observed at 2.5 J after 48 h [Figure 3] and pigmentation was observed after 5 days.Figure 1: Psoralen completely soluble in cleansing lotionFigure 2: Psoralen and cleansing lotion mixture applied over the backFigure 3: Erythema observed after 48 h at 2.5 JOral PUVASOL is effective but is time-consuming because the exposure to UV light occurs after 2 h and the intensity of sunlight varies. It also becomes difficult for children and working women. To overcome these issues bath PUVA was introduced, but it requires consumption of a large quantity of water. Pai and Srinivas introduced bathsuit tPUVA [2] to overcome this but the suit had to be worn for 15 min and was practically difficult. The main purpose of this study was to identify the method and use it with exposure to sunlight. The plan was to increase the concentration of psoralen rather increase the exposure time because we wanted to deliver it in a shorter period and the irradiance of sunlight was much lower than the irradiance of UV light in artificial chambers. The limitation was that it was done on a single subject, and the results might have varied. We plan to conduct further studies on a larger scale to determine the ideal dilution and use it as a viable alternative for delivering PUVA therapy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Efficacy of bath psoralen plus ultraviolet A for mycosis fungoides: A retrospective analysis of 62 cases

Efficacy of bath psoralen plus ultraviolet A for mycosis fungoides: A retrospective analysis of 62 cases

Guidelines for bath PUVA, bathing suit PUVA and soak PUVA.

The aim of these guidelines is to encourage dermatologists to use bath psoralen plus ultraviolet A (PUVA), bathing suit PUVA and soak PUVA in the treatment of psoriasis vulgaris and other conditions. Evidence was collected using searches of the PubMed, MEDLINE and COCHRANE databases using the keywords "bath PUVA," "soak PUVA," "bathing suit PUVA" and "turban PUVA." Only publications in English were reviewed. One hundred and thirty-eight studies were evaluated, 57 of which fulfilled the criteria for inclusion. Both bath PUVA and bathing suit PUVA are very effective and safe treatments for generalized stable plaque psoriasis (strength of recommendation, A). Soak PUVA is very effective in the treatment of both palmoplantar psoriasis and chronic palmoplantar eczema (strength of recommendation, A).

Bath psoralen–UVA photochemotherapy for localized scleroderma: experience from a single institute

Localized scleroderma (LS) comprises a spectrum of sclerotic autoimmune diseases primarily affecting the dermis. Various treatment modalities have been recommended for the management of LS, but only a few studies exist regarding the efficacy of bath PUVA photochemotherapy in the treatment of LS. To evaluate the efficacy of bath PUVA photochemotherapy in the management of LS in a retrospective study. Twenty-eight patients (23 women and five men) with a diagnosis of LS, confirmed by histology, were included in the study. Patients were treated with a thrice-weekly regimen of bath immersion in 0.2 mg/1 water solution of 8-methoxypsoralen, followed by irradiation with UVA. Eleven patients (39%) showed complete remission (complete softening of the sclerotic plaques with or without postinflammatory hyper- or hypopigmentation) after a mean of 71 treatments (range 33-170) and a mean cumulative dose of 115 J/cm(2) (range 11-232). Partial softening and regression of the sclerotic plaques was observed in 14 patients (50%). Three patients (10.7%) showed no effect, and in none of the patients was worsening noted during treatment. In our experience, bath PUVA photochemotherapy is an effective and well-tolerated treatment option for LS and should be considered as one of the first-line treatment modalities.

Efficacy of bath psoralen plus ultraviolet A (PUVA) vs. system PUVA in psoriasis: a prospective, open, randomized, multicentre study

Plaque psoriasis is an inflammatory disease affecting approximately 2% of the population. The clinical hallmarks of psoriasis are sharply demarcated, erythematous plaques with thick scales. Photochemotherapy (psoralen plus ultraviolet A, PUVA) is one of the most effective therapies of psoriasis. The photosensitizer 8-methoxypsoralen (8-MOP) can be applied either orally (system PUVA) or topically in a warm water bath (bath PUVA). To compare bath PUVA and system PUVA in the treatment of plaque psoriasis. This was a randomized, open, prospective, multicentre trial. We included 74 patients with moderate-to-severe plaque psoriasis during a 6-week treatment and a 4-week follow-up period. Of the patients enrolled in the study, 38 received bath PUVA and 36 system PUVA. Both treatment modalities significantly reduced the median Psoriasis Area and Severity Index (PASI) score in the intention-to-treat population. Within 6 weeks bath PUVA reduced the median PASI by 74% (16·4 to 4·2) while system PUVA did so by 62% (15·3 to 5·8). The difference between the two modalities was not significant with regard to treatment efficacy (P = 0·389). There is no difference between bath PUVA and system PUVA in the treatment of psoriasis.

Narrowband UVB as an effective substitute for psoralen plus UVA: lessons from a psoralen shortage

From March to August 2010, there was a shortage of encapsulated liquid 8-methoxypsoralen (8-MOP), the psoralen used for bath psoralen plus UVA (PUVA) in Toronto, Canada. Patients were forced to discontinue bath PUVA treatment and were transitioned to other therapeutic modalities, including narrowband UVB (nbUVB). A retrospective chart review was conducted of all patients who discontinued bath PUVA due to the unavailability of 8-MOP, with a focus on those who were switched to nbUVB. Sixty-three patients discontinued PUVA, 39 of whom were switched to nbUVB. Fifteen of 17 patients with mycosis fungoides (MF) who were switched to nbUVB improved, and patients with earlier-stage disease were more likely to improve. Ten of 13 (77%) psoriasis patients improved with nbUVB, including two patients whose psoriasis cleared completely. All three small-plaque parapsoriasis patients who switched to nbUVB had complete clearance of their lesions. In conclusion, nbUVB may be a suitable alternative for patients with MF, small-plaque parapsoriasis and psoriasis who cannot access PUVA therapy.

Lichenoid drug reaction to antituberculosis drugs treated through with topical steroids and phototherapy

Lichenoid drug reaction to antituberculosis drugs treated through with topical steroids and phototherapy

Treatment of acquired reactive perforating collagenosis with allopurinol incidentally improves scleredema diabeticorum

To the Editor: Acquired reactive perforating collagenosis is a condition characterized by altered collagen eliminated through the epidermis. It is usually associated with diabetes mellitus and chronic renal disease. Oral allopurinol has been described to be effective in treating acquired reactive perforating collagenosis. 1 Querings K. Balda B.R. Bachter D. Treatment of acquired reactive perforating collagenosis with allopurinol. Br J Dermatol. 2001; 145: 174-176 Crossref PubMed Scopus (33) Google Scholar Scleredema diabeticorum (SD) is also a dermatological complication of diabetes mellitus. It is characterized by diffuse swelling and nonpitting induration of the skin, especially on the upper trunk and neck. The histologic findings include a thickened broad dermis with mucin between thickened collagen bundles. SD is difficult to treat. Many therapies, including ultraviolet (UV) A1 phototherapy, bath psoralen UVA, narrowband UVB, extracorporeal photopheresis, radiation, electron beam, cyclosporine, methotrexate and high-dose penicillin, have been reported to be effective in separate cases. We report a case of acquired reactive perforating collagenosis treated with allopurinol treatment. Surprisingly, the concomitant SD improved simultaneously. This case implied the therapeutic effect of allopurinol in SD.

Bath psoralen+ultraviolet A photochemotherapy vs. narrow band-ultraviolet B in psoriasis: a comparison of clinical outcome and effect on circulating T-helper and T-suppressor/cytotoxic cells

Comparative success rates of bath psoralen+ultraviolet A (PUVA) and narrow band-ultraviolet B (NB-UVB) in psoriasis treatment are variably reported with no previous studies on the possible effect of bath PUVA on circulating CD4+ and CD8+ T cells. We aimed to compare the effect of bath PUVA and NB-UVB clinically and on circulating T-helper and T-suppressor/cytotoxic cells in psoriasis. Thirty-four psoriatic patients divided into a bath PUVA-treated group (18 patients) and a NB-UVB-treated group (16 patients) were compared regarding the disease severity by psoriasis area and severity index (PASI) score and percentage of circulating CD4+ and CD8+ T cells by flow cytometry before and after treatment. After treatment, the bath PUVA group showed a significantly higher reduction of PASI score (85.44%) than the NB-UVB group (58.72%). Mean peripheral CD4+ T-cell percentage was significantly lower after [36.8; 95% confidence interval (CI) 33.80, 39.97] compared with before treatment (42.06; 95% CI 38.29, 45.83) (P<0.05) in the bath PUVA group while this difference was insignificant in the NB-UVB group (P>0.05). Bath PUVA therapy is superior to NB-UVB in the treatment of moderate and severe psoriasis with mild reversible side effects. Both modalities have a systemic effect decreasing peripheral CD4+ T cells, which is more with bath PUVA.

Scleredema treated with broad-band ultraviolet A phototherapy plus colchicine

Scleredema is an uncommon condition characterized by induration of skin. The pathogenesis is not known, although the increased expression of collagen-producing fibroblasts in the skin has been demonstrated. Scleredema has been difficult to treat with scattered reports of success with bath psoralen plus ultraviolet A (PUVA), cream PUVA, UVA1 and others. The use of low-dose broad-band UVA phototherapy was found to be effective in the treatment of morphea. Colchicine has been shown to interfere with collagen synthesis and is used successfully in scleroderma. We report the first case of scleredema that improved markedly with low-dose broad-band UVA plus colchicine treatment.

Large plaque parapsoriasis with the “deck‐chair” sign successfully treated with bath psoralen and ultraviolet A therapy

Large plaque parapsoriasis with the “deck‐chair” sign successfully treated with bath psoralen and ultraviolet A therapy

Case of localized scleroderma successfully treated with bath psoralen and ultraviolet A therapy

The patient was a 12-year-old girl with linear scleroderma distributed on the right abdomen, dorsal aspect of the right thigh, lower leg and foot. The initial regimen of oral prednisolone and methotrexate, or i.v. methylprednisolone failed in the treatment of the scleroderma. Then bath psoralen and ultraviolet A therapy (bath-PUVA) therapy of 0.2 J-4.0 J/cm(2) daily to total doses 62.8 J/cm(2) combined with oral prednisolone was started. After bath-PUVA therapy, regression of the skin sclerosis was observed, the possible mobile range of the right ankle was increased and histological examination confirmed improvement of the sclerosis. The successful results of bath-PUVA therapy in this case suggest its utility for localized scleroderma.

Randomized, double-blind comparison of 1 mg/L versus 5 mg/L methoxsalen bath-PUVA therapy for chronic plaque-type psoriasis

Bath-psoralen plus ultraviolet A (PUVA) radiation therapy is increasingly replacing oral PUVA because of its superior short- and long-term safety profile. Several investigations in recent years have led to a refinement of the bath-PUVA protocol; however, the optimal therapeutic concentration of methoxsalen in the bath water has as yet not been delineated. The therapeutic efficacy and tolerability of bath-PUVA by using two different dilutions of methoxsalen (1 mg/L vs 5 mg/L or 0.0001% vs 0.0005%) were compared in 46 patients with chronic plaque-type psoriasis in a prospective, randomized, double-blind study. Scores of the Psoriasis Area and Severity Index excluding psoriasis of the head (PASI(TUL)) and the Plaque Severity Index (PSI) were assessed at baseline and at biweekly intervals thereafter until (near)complete clearance or maximal improvement. In addition, methoxsalen plasma levels were determined immediately after the psoralen bath during the first week of treatment and treatment-related side effects were recorded throughout the entire study period. The median baseline PASI(TUL) score decreased from 11.7 (7.5-32.8) to 3.3 (0.6-1.2) (-72%) in the 1 mg/L methoxsalen group and from 10.8 (6.6-20.7) to 1.4 (03.2) (-87%) in the 5 mg/L methoxsalen group (P < .01). The median baseline PSI score decreased from 9 (6-12) to 3.1 (0.6-10) (-66%) in the 1 mg/L methoxsalen group and from 9.3 (7.3-12) to 1.6 (0-3.6) (-83%) in the 5 mg/L methoxsalen group (P < .01). The median cumulative UVA exposure dose was 25.4 (5.3-81.5) J/cm2 for 5 mg/L methoxsalen and 71.9 (20.7-587.3) J/cm2 for 1 mg/L methoxsalen (P = .001). The number of exposures (22 [11-29] vs 23 [11-34]) and treatment duration (43 [19-68] vs 44 [23-66] days) was comparable for both methoxsalen dilutions (P = .97). Median psoralen plasma levels were 0 (0-26) ng/mL after the 1 mg/L and 30 (0-64) ng/mL after the 5 mg/L methoxsalen immersion (P = .001). Mild to moderate adverse events were more common in the 5 mg/L methoxsalen group. The conclusions of this randomized controlled study are limited by the relatively small sample size. Our data indicate that in bath-PUVA treatment the use of a high (5 mg/L) methoxsalen concentration is substantially more effective in clearing chronic plaque-type psoriasis than a low (1 mg/L) concentration.

Successful treatment of lichen amyloidosis with combined bath PUVA photochemotherapy and oral acitretin

Lichen amyloidosis (LA) is a chronic, pruritic skin disorder characterized by brownish-grey papules on extensor surfaces of legs and rarely on the trunk. Thioflavin T-positive amyloid deposits are found in the papillary dermis of affected skin, which is the only organ involved. A variety of therapeutic regimens for lichen amyloidosis have been described; however, in many cases with only limited effect. We report on two patients with lichen amyloidosis with typical clinical symptoms not responding to local treatment. A combined regimen with bath psoralen ultraviolet A (PUVA) and oral acitretin was initiated, resulting in nearly complete resolution of the papules and impressive relief from the severe pruritus. The beneficial response has persisted for 8 months. The suggested combined therapy with bath PUVA photochemotherapy and oral acitretin represents an efficacious and practical treatment modality for lichen amyloidosis with long-lasting effects.

Plasma levels of 8-methoxypsoralen after bath-PUVA for psoriasis: relationship to disease severity.

Plasma levels of 8-methoxypsoralen (8-MOP) were determined by high-pressure liquid chromatography in 19 patients with psoriasis who were receiving bath-PUVA treatment, at different time points after the psoralen bath. The levels of 8-MOP varied between < 5 ng/ml (lower limit of detection) and 34 ng/ml, and we found a relationship between the plasma psoralen levels and the severity of the disease.