Total UVA Dose Research Articles

Staphylococcus aureus resists UVA at low irradiance but succumbs in the presence of TiO2 photocatalytic coatings

The aim of this study was to evaluate the bactericidal effect of reactive oxygen species (ROS) generated upon irradiation of photocatalytic TiO2 surface coatings using low levels of UVA and the consequent killing of Staphylococcus aureus. The role of intracellular enzymes catalase and superoxide dismutase in protecting the bacteria was investigated using mutant strains. Differences were observed in the intracellular oxidative stress response and viability of S. aureus upon exposure to UVA; these were found to be dependent on the level of irradiance and not the total UVA dose. The wild type bacteria were able to survive almost indefinitely in the absence of the coatings at low UVA irradiance (LI, 1 mW/cm2), whereas in the presence of TiO2 coatings, no viable bacteria were measurable after 24 h of exposure. At LI, the lethality of the photocatalytic effect due to the TiO2 surface coatings was correlated with high intracellular oxidative stress levels. The wild type strain was found to be more resistant to UVA at HI compared with an identical dose at LI in the presence of the TiO2 coatings. The UVA-irradiated titania operates by a “stealth” mechanism at low UVA irradiance, generating low levels of extracellular lethal ROS against which the bacteria are defenceless because the low light level fails to induce the oxidative stress defence mechanism of the bacteria. These results are encouraging for the deployment of antibacterial titania surface coatings wherever it is desirable to reduce the environmental bacterial burden under typical indoor lighting conditions.

Efficacy and safety of topical PUVA treatment for refractory lesions of mycosis fungoides

To evaluate the efficacy and safety of topical PUVA treatment of refractory lesions of mycosis fungoides. From January 2008 to 2014, a total of 10 patients (4 males and 6 females) with mycosis fungoides were treated with topical PUVA in Peking Union Medical College Hospital, including 7 cases in plaque stage and 3 cases in tumor stage. The average number of lesions were 1.9±0.9. The median age of these patients was (46.0±9.4) years. The average course of disease was (12.4±7.7) years. Psoralen was applied topically on treatment area 30 min before total body UVA irradiation treatment, 3 times a week. And the efficiency and safety of the therapy were evaluated. All the patients were treated with topical PUVA with a median total dose of (161.60±135.96) J/cm2 in an average of (18.10±14.61) fractions. Total dose of UVA was (1 953.25±829.73) J/cm2, and total number of treatment was (261.90±116.79) fractions. The total treatment time was (45.80±26.64) months. Complete clinical response (CR) rate was 60.0%, partial response (PR) rate was 30.0%, and the overall response rate (CR+PR) was 90.0%. One patient showed no response. No severe acute or chronic side effects were observed. Topical PUVA therapy is effective in the treatment of refractory lesions of mycosis fungoides with little severe side effects.

Risk of Cutaneous Malignancy in Mycosis Fungoides Patients Treated with PUVA: A Retrospective Study

Istanbul Universitesi Istanbul Tip Fakultesi, Dermatoloji Anabilim Dali, Istanbul, Turkiye @Telif Hakki 2015 Turk Dermatoloji Dernegi Makale metnine www. turkdermatolojidergisi.com web sayfasindan ulasilabilir. @Copyright 2015 by Turkish Society of Dermatology Available on-line at www.turkdermatolojidergisi.com Melike Umarova Aslan, Istanbul Universitesi Istanbul Tip Fakultesi, Dermatoloji Anabilim Dali, Istanbul, Turkiye E-posta: melikeumarova@hotmail.com Gelis Tarihi/Submitted: 27.08.2014 Kabul Tarihi/Accepted: 02.12.2014 Yazisma Adresi/ Correspondence: Objective: PUVA therapy is mostly used longer than other diseases in mycosis fungoides (MF) patients. We aimed to investigate the chronic side effects of PUVA therapy, including skin cancer to disclose the actual risk in Turkish population. Methods: We screened all MF patients treated with PUVA at the Department of Dermatology and Venereology of Istanbul Medical Faculty and included patients in whom PUVA has first initiated between 1994 and 2006 and administered in one or several courses and who were followed up more than five years with last visit in 2012. Results: Fifty patients with MF had a mean follow-up duration of 10.2±2.8 years. Six patients (12%) had PUVA lentigines. Two of them (4%) developed skin cancer (basal cell carcinoma, Bowen’s disease) during their follow-up. The mean sessions (295.5±7.8 sessions) and total UVA doses (1452 J/cm2) in these patients with skin cancer were higher than those who did not develop skin cancer (128.7±73 sessions and 515±31 J/ cm2, respectively). There was a significant relationship between the PUVA lentigines and development of cutaneous malignancy (p=0.01). Ozgun Arastirma / Original Investigation 12 Turk J Dermatol 2015; 1: 12-7 • DOI: 10.4274/tdd.2413 13 Umarova Aslan ve ark. PUVA Tedavisinde Deri Kanseri Riski. Turk J Dermatol 2015; 1: 12-7 Conclusion: Cutaneous malignancies were detected in 4% of MF patients followed up approximately 10 years. Due to this low risk, we conclude that PUVA therapy is relatively safe in patients with MF in our country. However, UVA should not be applied in high total doses and patients should be followed-up lifelong.

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.

Efficacy and safety of bexarotene combined with psoralen-ultraviolet A (PUVA) compared with PUVA treatment alone in stage IB-IIA mycosis fungoides: final results from the EORTC Cutaneous Lymphoma Task Force phase III randomized clinical trial 21011 (NCT00

Psoralen plus ultraviolet A (PUVA) is the standard treatment for early stages of mycosis fungoides. There have been no adequate randomized controlled trials with sufficient power comparing this modality with other therapies. To assess disease response and to compare the response rates of patients treated with PUVA alone or PUVA and bexarotene. EORTC 21011 (NCT 00056056) was a randomized phase III study comparing combined bexarotene (Targretin(®) ) and PUVA vs. PUVA alone in patients with stage IB and IIA mycosis fungoides (MF). The primary endpoint was the overall response rate [complete clinical response (CCR) plus partial response (PR)]. The study was prematurely closed due to low accrual after 93 of 145 required patients (65%) were randomized. Of the 93 randomized patients, 87 started treatment, 41 received PUVA and 46 received PUVA + bexarotene. Total UVA doses received were 107 J cm(-2) (range 1·4-489·9) in the PUVA arm vs. 101·7 J cm(-2) (0·2-529·9) in the combination arm. The safety profile was acceptable with few grade 3-4 toxicities observed in either arm. More drop-outs due to toxicity were observed in the combination arm compared with the PUVA-alone arm. The best overall response (CCR + PR) rate was 71% for PUVA alone and 77% for the combination arm (P = 0·57). The median duration of response was 9·7 months for PUVA vs. 5·8 months for the combination arm (P = 0·33). CCR was seen in 25 patients of whom 10 received PUVA alone (CCR 22%) and 15 received combination therapy (CCR 31%) (P = 0·45). CCR was sustained in 25% of patients regardless of therapy. There was a trend towards fewer PUVA sessions needed to achieve CCR in the combination arm (median 22) compared with the PUVA arm (median 27·5) (P = 0·11). Similarly, a trend towards lower UVA dose required to achieve CCR in the combination arm (median 55·8 J cm(-2) ) compared with the PUVA arm alone (median 117·5 J cm(-2) ) (P = 0·5) was observed. No significant difference in response rate or response duration was observed in this study. However, there was a trend towards fewer PUVA sessions and lower UVA dose required to achieve CCR in the combination arm (PUVA + bexarotene) but this did not achieve statistical significance due to insufficient power.

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.

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.

Relating daily solar ultraviolet radiation dose in salt marsh‐associated estuarine systems to laboratory assessments of photoactivated polycyclic aromatic hydrocarbon toxicity

Estuaries of the southeastern United States not only serve an important nursery function but also are common repositories of polycyclic aromatic hydrocarbons (PAHs) derived from upland activities. Thus, these habitats may be at risk for PAH phototoxicity. To better characterize this risk, a daily survey of ultraviolet-A (UV-A; 320-400 nm) irradiance was performed at Leadenwah Creek (Wadmalaw Island, SC, USA) on June 27 and August 1, 2003. In addition, laboratory assays were completed using two light exposure regimes: One that was typical of historical phototoxicity assessments (continuous light [C-UV]), and a more environmentally realistic regime (ER-UV). On both survey days, irradiance at a depth of 10 cm exhibited a pattern generally similar to that observed at the surface, whereas irradiance at the bottom of the creek was a function of both tidal height and time of day. Total UV-A dose at a 10-cm depth on June 27 and August 1, 2003 was 4.37 and 4.78 J/cm2, respectively. Attenuation coefficients on both days varied as a function of tidal height. In the laboratory, larval grass shrimp (Palaemonetes pugio) exposed to an ER-UV regime for these habitats (photoperiod, 12:12-h light:dark; total daily UV-A dose, 4.40 J/cm2) exhibited a 2.5-fold decrease in toxicity compared with those exposed to the C-UV regime (photoperiod, 24:0-h light:dark; total daily UV dose, 1.50 J/cm2), despite a threefold higher UV dose in the ER-UV regime. The lower potency under the ER-UV regime likely is attributable to the presence of a 12-h dark period allowing for recovery. The consequences of these results are discussed in the context of habitat-specific UV-A dose and its relevance to future laboratory assessments of PAH phototoxicity.

PUVAthérapie et cancers cutanés: Etude rétrospective chez 106 malades ayant reçu des doses élevées de PUVA

The benefits of PUVAtherapy in many dermatological affections are well known. Its carcinogenic role in the long term has been assessed varyingly in American and European series. The aim of this study was to assess the role of PUVA in the onset of cancers of the skin. Retrospective study of patients presenting with psoriasis and followed-up in the phototherapy unit of the Michallon Hospital in Grenoble since 1976 and having received more than 150 sessions of PUVA. The parameters studied were: age, gender, phototype, age at the time of the first irradiation, type of phototherapy administered, total number of sessions, concomitant treatments, administration of retinoids and the appearance of skin cancers with the interval before their onset after the first session, their localization and their histological type. One hundred six patients were retained among the 152 who replied to the inclusion criteria. Having died or been lost to follow-up, forty-six patients were excluded. Fourteen patients had presented at least one cutaneous tumor with a total number of 35. Excluding the keratoacanthomas, 13 patients had a non-melanic cutaneous cancer with a total number of 32 tumors. Ten out of the 14 were phototype III, 3 were phototype II and one was phototype IV. Nine out of 14 had received PUVAtherapy alone and 5 PUVAtherapy and broad spectrum UVB. The number of sessions of PUVA received in all the cases was more than 200 (220 to 780), corresponding to a total dose of UVA comprised between 1460 and 3882 Joules. The delay before onset of the tumors varied from 6 to 27 years after the first PUVAtherapy. The mean age at the time of the first irradiation was of 50.2 years (14-75 years). The mean duration of phototherapy was of 10 years (2.23 years).

A combination therapy of calcipotriol cream and PUVA reduces the UVA dose and improves the response of psoriasis vulgaris

BACKGROUND: The addition of calcipotriol ointment to PUVA therapy for psoriasis vulgaris results in a lower total UVA dose and a faster onset of response. The addition of calcipotriol cream to PUVA, however, has not been studied.OBJECTIVE: To investigate whether combining calcipotriol cream with PUVA therapy has a UVA sparing effect.METHODS: We performed a randomized, multicentre, vehicle‐controlled, double‐blind, 12‐week comparative study including 120 patients with psoriasis covering 20–50% body surface area. The study consisted of a washout phase followed by a 10‐week treatment phase. PUVA therapy three times weekly was added within 1 week after randomization. Efficacy was assessed by the Psoriasis Area and Severity Index (PASI).RESULTS: At baseline the mean PASI scores were 17.5 and 19.2 in the calcipotriol and vehicle (placebo) groups, respectively. At the end of treatment, the mean PASI scores were 2.65 and 7.03 (p<0.01), respectively. A reduction in PASI score >90% was observed in 69% of the patients in the calcipotriol‐treated group and in 36.4% of the patients in the vehicle group (p<0.01).CONCLUSION: Calcipotriol cream plus PUVA clearly reduces the cumulative dose of UVA and improves the response of psoriasis vulgaris to PUVA.

Comparison of calcipotriol-PUVA with conventional PUVA in the treatment of psoriasis

AIM: To compare the therapeutic efficacy of calcipotriol-PUVA therapy and PUVA in Korean patients with psoriasis. METHODS: A total of 38 patients were treated with conventional PUVA and 37 with calcipotriol PUVA. A comparison was made between the total number of PUVA treatments and the total UVA dose required to reach clearance in the two groups. Thereafter, categorization into clearing, improvement and failure was undertaken, with measurement of the psoriasis area and severity index made at each visit. RESULTS: Cumulative UVA dose as well as the number and duration of treatments in the calcipotriol-PUVA group were significantly lower than in the PUVA-treated group. Some 86% of patients treated with calcipotriol-PUVA showed clearing compared with 66% of those treated by PUVA. In the calcipotriol-PUVA group, the patients with only moderate extent required fewer irradiation treatments, shorter durations of treatment, and a lower final and cumulative UVA dose to reach clearance than the severely affected group. CONCLUSION: Combining PUVA with calcipotriol in the treatment of psoriasis may reduce the risks of long-term UV radiation and improve the clinical response. (J Dermatol Treat (2000) 11:125-130)

Comparison of 8-MOP Aqueous Bath and 8-MOP Ethanolic Lotion (Meladinine®) in Local PUVA Therapy

Background and Objective: Local PUVA (psoralen plus UVA light) is an effective outpatient treatment for patients with palmoplantar eczema or psoriasis. In this study, the efficacy, applicability and patient acceptance of two local forms of 8-methoxypsoralen (8-MOP) PUVA therapy were compared. Methods: The study design was a left-right comparison (n = 37): the left hand or foot was treated with (aqueous) 8-MOP bath PUVA whereas the right received (ethanolic) 8-MOP lotion PUVA. After 1 month, the more successful treatment was continued on both sides until lesions cleared. Results: Both therapies were effective and both useful for particular clinical applications: patients with erosive lesions and rhagades appreciated the gentleness of bath PUVA. Those with pustules or hyperkeratotic lesions appreciated the greater effectiveness of 8-MOP lotion PUVA. The total UVA dose and number of sessions to clearance were smaller with 8-MOP lotion. There was no difference in the length of the relapse-free period. Therapy nonresponders usually became apparent within the first 12 sessions. Conclusions: The difference between bath PUVA and lotion PUVA can be described as ‘gentle’ versus ‘strong’ therapy. The better therapy depends on clinical indication.

Cancer incidence among Finnish patients with psoriasis treated with trioxsalen bath PUVA

Background: Systemic methoxsalen PUVA increases nonmelanoma skin cancer risk in a dose-dependent manner, whereas trioxsalen bath PUVA treatment has been suggested to be less carcinogenic. Objective: Our purpose was to study the carcinogenicity of topical trioxsalen PUVA. Methods: We performed a record linkage study of 337 male and 190 female patients with psoriasis treated with trioxsalen bath PUVA during the period 1977 to 1988 and the Finnish Cancer Registry (cancer incidence in the period 1977 to 1993). The mean follow-up period per person was approximately 11 years. Data on the total cumulative UVA dose and other potentially carcinogenic treatments were collected from the patients' files. The standardized incidence ratio (SIR) was calculated, in which the expected number of cases was based on the national cancer incidence rates. Results: During the follow-up, 26 cancer cases were observed in the cohort versus 30 expected (SIR, 0.88; 95% confidence interval [CI], 0.57–1.28). The only primary sites showing high SIRs were cancer of the kidney (SIR, 3.56; 95% CI, 0.97-9.10) and non-Hodgkin's lymphoma (SIR, 2.94; 95% CI, 0.36–10.6). There was only one case of nonmelanoma skin cancer; the expected number was 0.8 (SIR, 1.26; 95% CI, 0.03–7.04). The average cumulative UVA dose was 65 J/cm 2; 40 patients had received more than 200 J/cm 2. The average number of treatments was 112; 65 patients had received more than 200 treatments. Conclusion: No excess of squamous cell carcinoma of the skin was found in patients treated with trioxsalen bath PUVA. However, because of the small size of the cohort, only a sevenfold excess risk can be excluded. The possible associations between psoriasis or its treatment and kidney cancer and lymphoma need to be studied further in larger series.

Treatment of psoriasis with polyethylene sheet bath PUVA

Background: Bath PUVA has been shown to be an effective alternative treatment for psoriasis with fewer systemic side effects than oral methoxsalen (8-MOP). The cost of 8-MOP and the need for a bath unit have prevented wider use of this treatment. Objective: We investigated the safety and efficacy of sheet bath PUVA by restricting the volume of the psoralen/bath water solution to 10 L with the aid of a polyethylene sheet. Methods: Fifty-eight patients with chronic plaque-type psoriasis were treated with bath PUVA in a concentration of 0.5 mg of 8-MOP per liter of water. Results: The group required a median of 17 baths (95% confidence interval [CI], 14–20) for clearance. Total UVA dose for the entire group was 26 J/cm 2(95% CI, 18–47). Conclusion: Sheet bath PUVA is safe, efficient, and easy. This regimen can significantly reduce the amount of 8-MOP required, thereby resulting in a favorable cost/benefit ratio.

Foil bath PUVA in the treatment of prurigo simplex subacuta.

Prurigo simplex subacuta is a chronic pruritic condition of unknown aetiology. The skin lesions respond to topical corticosteroids, UV-A and UV-B therapy only to a limited degree. Ten patients suffering from prurigo simplex subacuta were treated with foil bath PUVA at a concentration of 0.5 mg 8-methoxypsoralen/l. Using the foil bath method the volume of the psoralen/bath-water solution is restricted to 10 l with the aid of polyethylene foil. The group required a median of 13 (95% CI: 9-19) baths for clearance. The total UV-A dose for the whole group was 19 (95% CI:5-30) J/cm2. Bath PUVA is a safe and well-tolerated therapy in the treatment of prurigo simplex subacuta.

Photo(chemo)therapy and general management of erythropoietic protoporphyria.

Erythropoietic protoporphyria is an autosomal dominant or autosomal recessive photodermatosis characterized by a deficiency of the enzyme ferrochelatase. The diagnosis is based on the very typical complaints of burning and pain on sun exposure and on increased protoporphyrin concentration in the red blood cells, the plasma and the feces. Different treatment modalities have been proposed. The treatment of choice has always been beta-carotene. For severe cases, PUVA treatment can be given three times a week until a total UVA dose of 120-200 J/cm2. In younger children, UVB phototherapy can be used if beta-carotene gives unsatisfactory therapeutic results. The irradiations are given four times a week until a total dose of 1-1.5 J/cm2 is reached.

紫外線療法施行中の乾せん患者に生じたｍａｌｉｇｎａｎｔ ｍｅｌａｎｏｍａ ｉｎ ｓｉｔｕの１例

A 68-year-old Japanease man was refered to us a developing black-brown macule on the left posterior thoratic region at 10 years after treatment for his psoriasis. He received photochemotherapy (PUVA) every two weeks in our hospital from March, 1983. The dose of 8-methoxypsoraren was 40mg/body and UVA dose were 5-9 Joule/cm2. Besides this he began UVB therapy with home use of sunlamps twice a week. From July, 1986 through June, 1993 the patient sporadically received PUVA for each flares of psoriasis. Total UVA dose was about 800 Joule/cm2. Total UVB dose was unknown. He had not received X-ray, tar, methotrexate nor arsenic treatment before his starting photo (chemo) therapy. In June, 1993 he noticed a pigmented macule on his back. Histologically, it was diagnosed as a malignant melanoma in situ. Patients treated with PUVA and/or UVB should be kept under surveillance for the development of cutaneous malignant neoplasms, including melanoma, although the incidence of photo (chomo) therapy-induced malignant tumor is very low in Japanease peoples.

Acitretin in combination with PUVA: a randomized double‐blind placebo‐controlled study in severe psoriasis

AbstractObjectives To investigate the therapeutic efficacy of acitretin + PUVA compared to placebo + PUVA in terms of improvement assessed by the Psoriasis Severity Index (PSI) and total UVA dosage.Design Double‐blind, randomized, parallel, multicenter study over 8 weeks.Indication Generalized chronic plaque or exanthematic type of psoriasis severe enough to require PUVA treatment.Targets Decrease of PSI at the end of the study; response defined as improvement of PSI≥ 75% with respect to baseline, total UVA dosage applied and UVA dosage applied up to response.Statistical methods PSI changes (baseline up to end of treatment) in the two groups were compared at the 5% significance level using the Kolmogoroff‐Smirnoff test (2‐tailed). In addition, descriptive statistics for comparison of response rates (Chi2 test) and total UVA dosage as well as UVA dosage applied up to response (life‐table analysis by Kaplan‐Meier) were performed.Results Patients Forty patients (36 males. 4 females) in the placebo + PUVA and 43 patients (32 males, 11 females) in the placebo + PUVA group were investigated for efficacy. Twenty‐three patients of the acitretin + PUVA group and 25 patients of the placebo + PUVA group ceased treatment prematurely. PSI The median PSI decrease was 24 (89%) score points in the acitretin + PUVA group and 21 (83%) in the placebo + PUVA group (P &gt; 0.05, Kolmogoroff‐Smirnoff test). The response rate was 34 out of 40 (85%; 95% CI 70‐94%) in the acitretin + PUVA group and 26 out of 43 (60%; 95% CI 44–75%) in the placebo + PUVA group (P= 0.013. Chi2 test: descriptive). Complete remission The clinical outcome as assessed by the investigator was complete remission in 28 patients of the acitretin + PUVA group and 19 patients of the placebo + PUVA group. Premature discontinuation of treatment due to complete remission was possible in 16 patients of the acitretin + PUVA group and 11 patients of the placebo + PUVA group. UVA dosage The total UVA dose applied was 77.6 J/cm2 (SEM = 9.2 J/cm2) in the acitretin + PUVA group and 73.0 I/cm2 (SEM = 7.2 J/cm2) in the placebo + PUVA group. The median UVA dose up to response was 52.0 J/cm2 in the acitretin + PUVA group and 74.5 J/cm2 in the placebo + PUVA group. Tolerability In both treatment groups, adverse events were frequent. Mucocutaneous adverse events, such as dry lips, mouth and nose and dryness and scaling of the skin, were the most common complaints in both groups, but more pronounced in the acitretin + PUVA group. Treatment of adverse events included mainly indifferent ointments, non‐steroidal, anti‐inflammatory drugs and anti‐puritic agents and tranquilizers. Treatment had to be discontinued due to adverse events in three patients of each group. In the acitretin + PUVA group, the reasons were acral‐bullous photodermatosis due to PUVA, increased liver enzymes and increased triglycerides, respectively. In the placebo + PUVA group, one patient developed sensori‐neural loss of hearing, one stomach pain, nausea and colics of the upper abdomen and one increased triglycerides, cholesterol and liver enzymes.Conclusions Difference in improvement of the PSI was not statistically significant between the acitretin + PUVA and the placebo + PUVA groups. However, the response rates (75% PSI decrease) and complete remission as assessed by the investigator for acitretin + PUVA was superior to PUVA alone. The UVA‐saving effect could not be confirmed although the UVA dose applied up to response was less in the acitretin + PUVA group. Overall, acitretin was found to enhance the therapeutic efficacy of PUVA in patients with severe psoriasis.

A trial of accelerated PUVA in psoriasis

Ten psoriatic patients were treated with an accelerated PUVA regimen. Nine patients cleared in an average of 13.7 treatments (range 4-24) after an average total UVA dose of 83 J/cm2 (range 18-186). One patient had to withdraw due to pruritus and burning and six others had burning problems. The high incidence of burning may limit the routine use of this irradiation regimen.

8-MOP bath PUVA for psoriasis in the West Midlands

8-MOP bath PUVA was compared with 8-MOP oral PUVA in 40 patients with chronic plaque psoriasis to determine the relative efficacy, adverse effects, cost and induced photosensitization. Bath PUVA cleared psoriasis more rapidly than oral PUVA (mean time to clearance (± s.e), 7.1 ± 0.6 weeks vs 10.3 ± 0.9 weeks; P < 0.01), and required fewer treatments (mean number, 20.0 ± 1.7 vs 28.3 ± 2.1; P < 0.01), a lower final UVA dose (mean dose, 2.1 ± 0.2 J/cm2 vs 6.0 ± 0.5 J/cm2; P < 0.001) and a lower total UVA dose (mean dose, 28.3 ± 4.7 J/cm2 vs 110.7 ± 13.8 J/cm2; P < 0.001). Systemic symptoms, chiefly nausea, experienced by two-thirds of patients receiving oral PUVA were absent in the bath PUVA group. The incidence of acute cutaneous adverse effects (pruritus, burning and pain) were similar for both groups. Bath PUVA was more expensive than oral PUVA (cost of a clearing course: £ 69.80 vs £ 30.80). In a study of minimum phototoxic dose determination, bath-water delivery of 8-MOP induced approximately eight time...