The efficacy of narrowband ultraviolet B phototherapy in psoriasis using objective and subjective outcome measures

The efficacy of narrowband ultraviolet B (UVB) was assessed in 100 consecutive patients with psoriasis by quantifying disease severity using objective (Psoriasis Area and Severity Index, PASI and Dermatologists Global Assessment, DGA) and subjective (Psoriasis Disability Index, PDI) measures. The median pretreatment PASI, DGA and PDI were 5.7 (interquartile range, IQR 4.5-8.35), 7 (IQR 6-9) and 42 (IQR 29-63.5), respectively. At 3 month follow-up, the PASI, DGA and PDI had fallen to 2.7 (IQR 1.1-3.5), 3 (IQR 2-5) and 30 (IQR 21-50.5), respectively (P < 0.001). A small group of patients continued to score highly on their PDI despite being clinically clear or having minimal disease, possibly representing chronic disability behaviour. Patients exhibiting this may require more intensive supervision. In most patients, symptoms of itch and pain improved or disappeared (70% and 75%, respectively). Side-effects were reported in 18%. Narrowband UVB phototherapy is safe and effective for psoriasis. Symptoms and subjective quality of life measures improved significantly. Both objective and subjective measures should be used when evaluating the efficacy of a treatment for psoriasis.     

Evaluation of a multicentre study of synchronous application of narrowband ultraviolet B phototherapy (TL-01) and bathing in Dead Sea salt solution for psoriasis vulgaris

The synchronous application of narrowband UVB phototherapy with 311 nm lamps (Philips TL-01) and bathing in Dead Sea salt solution was evaluated in a multicentre trial (n = 60) in outpatients suffering from psoriasis vulgaris. The study design consisted of an initial therapy phase of up to 35 treatments (three to five times a week) followed by maintenance therapy with up to 35 further applications (once or twice a week). Evaluation was performed separately for patients in according-to-protocol (ATP) (n = 280) and intention-to-treat (ITT) (n = 692) groups. An overall significant improvement of the Psoriasis Area and Severity Index (PASI) score (P < 0.05) could be shown for both groups during initial therapy with 71.4% improvement for ATP and 61% for ITT patients. The mean PASI for ATP (values for ITT in parentheses) was 17.7 (18.6) at baseline, 9.5 (10.7) after 20 applications and 5.2 (7.4) at the end of initial therapy. On average, ATP patients received 3.9 (3.5) applications per week with a cumulative irradiation dose of 19.5 J cm-2 (16.2 J cm-2). The most frequent side-effect was erythema, observed in 8.7% of the patients. Subjective evaluation of the therapy by the patients (n = 168) was excellent. Seventy-nine per cent of patients preferred the new treatment strategy in comparison with other previous therapies and 88% regarded this therapy as pleasant and comfortable. In conclusion, we could demonstrate a significant effect of therapy in both the ATP and the ITT groups for this new treatment system which imitates, as far as possible, the Dead Sea climatic conditions, with no severe side-effects and a high acceptance by the patients.     

Current severe psoriasis and the rule of tens

This review addresses the problems of defining severity of psoriasis. Concepts of severity depend on the timescale perspective from which judgement is made. Measurement needs to include assessment of signs, impact on the patient's life and the history of the disease. The concept of severity in relationship to quality of life measurement scores has been defined, so it is now possible to postulate a standard, easily remembered concept to help define 'severe psoriasis' in the clinic. The proposed Rule of Tens for current severe psoriasis from the clinician's viewpoint is: 'Current Severe Psoriasis = Body Surface Area involved > 10% or Psoriasis Area and Severity Index score > 10 or Dermatology Life Quality Index score > 10'.     

Comparison of phototherapy two times and four times a week with low doses of narrow-band ultraviolet B in Asian patients with psoriasis

BACKGROUND/AIMS: The optimum narrow-band (TL-01) ultraviolet (UV) B weekly treatment frequency for psoriasis has yet to be defined, especially in Asian patients with TL-01. Our purpose was to compare 2 x weekly and 4 x weekly therapy with narrow-band UVB at low doses for psoriasis vulgaris. METHODS: Sixty-nine patients with moderately severe psoriasis were recruited and allocated to the 2 x weekly or 4 x weekly treatment group. The patients were treated with a new protocol using low doses of narrow-band UVB with varied exposure increments. Outcomes were evaluated by means of Psoriasis Area and Severity Index (PASI) scores, time (weeks), cumulative UVB dose and number of treatments to clearance. RESULTS: No significant difference was found between the two regimens in the PASI score at the end of treatment, in the proportion of patients whose skin cleared during treatment and in the time to clearance (8 weeks). Those who completed treatment achieved clearance after a median of 16 exposures with 2 x weekly treatment compared with 32 exposures with 4 x weekly treatment (P=0.0304), and 12.5 minimal erythema dose multiples (MEDs) compared with 39.7 MEDs (P=0.0470). Acute side effects of the treatment were similar for the two groups (P=0.8462). CONCLUSION: For skin phototype III-V populations, a greater long-term risk is expected, connected with the higher cumulative UVB dose and number of exposures required in the 4x weekly group. Therefore, 4 x weekly phototherapy will no longer be used for psoriasis.     

Folic acid supplementation during treatment of psoriasis with methotrexate: a randomized, double-blind, placebo-controlled trial

BACKGROUND: The value of folate supplementation in methotrexate (MTX)-treated patients remains controversial. OBJECTIVES: To determine the effect of folic acid (FA) on the efficacy of MTX and the frequency of side-effects associated with MTX therapy. METHODS: A 12-week double-blind clinical trial was conducted in patients with psoriasis stable on their long-term MTX doses but not receiving FA. They were randomized into two arms of either FA 5 mg or placebo daily. MTX doses were not changed throughout the study. Patients were monitored every 3 weeks by the same observer. Assessments included Psoriasis Area and Severity Index (PASI), a visual analogue scale (VAS) of patients' perception of their psoriasis severity and the Dermatology Life Quality Index (DLQI). Adverse events were systematically recorded. Haematological and biochemical monitoring was performed. RESULTS: Twenty-two patients with psoriasis were recruited. Age, sex and weekly MTX doses were similar in both groups. All 22 patients completed the study. The mean PASI in the FA group increased from 6.4 at baseline to 10.8 at 12 weeks. In the placebo group the mean PASI fell from 9.8 at baseline to 9.2 at 12 weeks. The mean change from baseline in the FA group was 4.4 vs. -0.6 in the placebo group (P < 0.05). Similar trends were observed in the changes in VAS and in the DLQI and differences between the groups were significant for both these parameters (P < 0.05). Few adverse effects were reported. CONCLUSIONS: This study suggests that supplementation with FA during long-term MTX treatment reduces the efficacy of MTX in the control of psoriasis. Due to the relatively small sample size and short duration of this study, no conclusions can be drawn regarding the possibility that FA may reduce the side-effects of MTX.     

Calcitriol vs. dithranol in combination with narrow-band ultraviolet B (311 nm) in psoriasis

BACKGROUND: Narrow-band ultraviolet (UV) B (311 nm) phototherapy is an effective treatment for psoriasis. In order to reduce cumulative UV doses and to enhance clearance of psoriasis plaques, combination therapies with topical agents such as dithranol and calcipotriol have been established. OBJECTIVES: To compare the clinical efficacy, in a half-side manner, of UVB (311 nm) in combination with either calcitriol or dithranol. METHODS: Ten patients with symmetrical stable plaque psoriasis were treated with narrow-band UVB (311 nm) five times a week. In addition, topical calcitriol was applied twice daily to one arm, whereas the other arm and the rest of the body were treated once daily with dithranol. The follow-up period was at least 4 weeks. Efficacy was assessed separately for both arms prior to treatment and once weekly thereafter by a modified Psoriasis Area and Severity Index (PASI) score. The cumulative irradiation dose and the number of treatment sessions required for clearance of psoriasis lesions were determined for each patient. Additionally, all patients completed a quality of life questionnaire. RESULTS: Both treatment modalities notably reduced the PASI score. A clinical comparison of UVB (311 nm) in combination with either calcitriol or dithranol revealed no significant therapeutic differences between the regimens. CONCLUSIONS: Combination of narrow-band UVB (311 nm) therapy with calcitriol is equally effective as the combination with dithranol for the treatment of psoriasis. However, patients preferred calcitriol rather than dithranol when both quality of life and treatment acceptability were assessed.     

311nm窄谱中波紫外线照射治疗寻常性银屑病疗效观察

目的观察311nm窄谱中波紫外线(NB-UVB)照射治疗寻常性银屑病的疗效及其影响因素。方法单独采用NB-UVB照射或联合糠馏油硼酸氧化锌软膏(PBZS)封包治疗寻常性银屑病87例,并以银屑病面积和严重度指数(PASI)评价疗效,分析性别、皮肤类型、临床分型及临床分期对疗效的影响,同时对采用其他方法治疗的30例寻常性银屑病患者进行回顾性的评价。结果在(17.60±4.42)d、(16.90±5.80)d、(25.80±6.67)d治疗后,NB-UVB组、NB-UVB+PBZS组及回顾分析组治疗前后PASI评分改善率分别为(76.3±24.6)%、(88.1±28.7)%、(76.5±26.2)%;与回顾分析组比较,NB-UVB组与其疗效相当(P>0.05),但治疗时间显著缩短(P<0.05),而NB-UVB+PBZS组则在更短的治疗时间(P<0.05)取得了更好的疗效(P<0.05);疗效相关因素分析表明,点滴状略优于斑块状、进行期略优于静止期(0.01相似文献   

窄谱中波紫外线对寻常性银屑病血管调节因子的作用机制研究

目的 探讨窄谱中波紫外线（NB-UVB）对寻常性银屑病患者皮损中微血管密度（MVD）、血管内皮生长因子（VEGF）和基质金属蛋白酶-2（MMP-2）以及血清中VEGF的影响。方法 采用葡聚糖聚合物标记免疫组化法对15例寻常性银屑病患者NB-UVB治疗前后的皮损标本中MVD以及VEGF、MMP-2的表达水平进行测定,采用ELISA法测定血清VEGF水平,以10份正常人皮肤标本和15份正常人血清作为对照;在NB-UVB治疗前后对银屑病皮损进行PASI评分。结果 寻常性银屑病患者治疗前皮损组织中MVD为20.52 ± 5.02（单位：个/400倍镜下）,明显高于治疗后（7.33 ± 1.24）和正常人对照组皮肤组织（4.26 ± 0.79）（F = 97.57,P < 0.05）,且治疗后PASI评分较治疗前显著降低（t = 13.35,P < 0.01）;治疗前血清中VEGF表达水平为307.55 ± 121.65 ng/L,明显高于治疗后（163.92 ± 95.57 ng/L）和正常人对照组（139.78 ± 79.06 ng/L）（F = 9.903,P < 0.05）,而治疗后VEGF表达水平与正常人对照组相比差异无统计学意义（P > 0.05 ）;银屑病皮损中MMP-2阳性表达在治疗前、后以及和正常人对照组之间的差异均无统计学意义（P ＞ 0.05）。银屑病患者PASI评分、MVD、皮损及血清中的VEGF表达四者互为正相关关系（P < 0.05）;皮损中的MVD、VEGF表达、MMP-2表达互为正相关关系（P < 0.05）;皮损中的MMP-2与PASI评分、血清中VEGF表达无相关关系（P ＞ 0.05）。结论 NB-UVB可以降低寻常性银屑病患者血清中VEGF的表达水平及其皮损中真皮浅层微血管增生状态;组织中VEGF、MMP-2可能共同参与了微血管的增生过程,但MMP-2没有参与NB-UVB对寻常性银屑病的治疗机制。     

Efficacy of ultraviolet B phototherapy for psoriasis in patients infected with human immunodeficiency virus

To evaluate the efficacy of ultraviolet B (UVB) phototherapy for the treatment of psoriasis in patients infected with human immunodeficiency virus (HIV), the response of 14 patients was compared to that of matched seronegative control individuals. All patients were evaluated prior to treatment (baseline) and after 21 treatments for the extent of total body surface area (TBSA) involvement and the quantification of scale, erythema, and thickness of plaques using a scale of 0 (absent) to 4 (severe). The only concomitant medication allowed was salicylic acid in petrolatum. The cumulative score for scale, erythema, and thickness improved 1.9± 0.5 [mean± standard error of mean (SEM)] in the HIV group and 2.4± 0.3 in controls. There was 40.9± 7.3 % reduction of TBSA involvement in the former and 38.4± 7.6 % reduction in the latter group. None of the differences was statistically significant. There was no statistically significant difference in the response to therapy among various stages of immunosuppression in the HIV group. There was also no deterioration of immune status in this group. UVB phototherapy is an effective treatment for psoriasis in patients infected with HIV. The response is identical to that of matched control individuals.     

Development of cutaneous tolerance to ultraviolet B during ultraviolet B phototherapy for psoriasis

During a schedule of multiple exposures to ultraviolet B radiation (UVB, 280–320 nm), skin develops a reduced sensitivity, variously called tolerance, photoadaptation, accomodation or acclimatization. In this study we have investigated the development of tolerance in the normal skin of a group of psoriatic patients during the course of UVB therapy Tolerance was assessed by phototests carried out on non-lesional skin as frequently as possible throughout the treatment. Maximum tolerance was developed by the group of individuals most sensitive to UVB, which was twice that of the least sensitive group. The minimal perceptible erythema dose (MPE) increased rapidly in the first 2 weeks (220% per week) and reached a plateau by the eighth week of 800% above the baseline MPE dose. For the more sensitive patients there was a further increase in sensitivity (decrease in MPE dose) after the ninth week of continuous treatment. Tolerance to UVB also involves pigmentation in the first few weeks, but in these patients there was no evidence of hyperpigmentation by the end of treatment. While epidermal hyperplasia is most likely to play a leading role in the development of tolerance to UV, there is no reason to expect this protection to decrease under conditions of continuous exposure. Thus, accommodation to ultraviolet radiation (UVR) is not a monotonically increasing process but appears to alter the accepted reactions of human skin to UVR.     

Efficacious treatment of psoriasis with low‐dose and intermittent cyclosporin microemulsion therapy

Cyclosporin is used for moderate to severe psoriasis and improves not only the skin lesions but also quality of life of the patients. To improve its safe use, we evaluated a low‐dose, intermittent regimen of cyclosporin in the treatment of psoriasis vulgaris. Seventy‐three patients received approximately 2.5 mg/kg per day of cyclosporin microemulsion twice daily before breakfast and dinner for 2–12 weeks until 75% reduction was achieved in Psoriasis Area and Severity Index (PASI) score. When the skin lesions relapsed after cessation of cyclosporin and showed less than 50% reduction from baseline in PASI score, cyclosporin was restarted. This cessation and restart cycle was repeated if necessary. Treatment outcomes were assessed at 12, 48 and 96 weeks after initiation of the therapy. The initial dose of cyclosporin was 2.32 ± 0.27 (standard deviation [SD]) mg/kg per day. At baseline, the mean PASI score was 11.3 ± 5.3 (SD). An average of 49.8 ± 23.8 (SD) days of the therapy achieved PASI 75% reduction. In 20 of 73 patients, the second course of cyclosporin was required. The mean interval between the first and second course was 94 days. An average of 60.8 ± 26.9 days was required to achieve PASI 75% reduction in the second course, which was not significantly longer than that in the first course. Only six patients required cyclosporin for 96 weeks. The adverse effects included one case of hypertension. Our study suggests that low‐dose, intermittent cyclosporin microemulsion is efficacious for the treatment of moderate to severe psoriasis.     

Incidence of skin cancers in 3867 patients treated with narrow-band ultraviolet B phototherapy

Background  Narrow‐band ultraviolet B (NB‐UVB) phototherapy is a widely used treatment. Psoralen‐UVA photochemotherapy (PUVA) increases skin cancer risk and some animal studies have raised the possibility of an increased risk with NB‐UVB. The risk of skin cancer in humans following treatment with NB‐UVB is unknown. Objectives  This current analysis forms part of an ongoing study ultimately aiming to define the long‐term carcinogenic risk of NB‐UVB treatment in humans. Methods  Details of all patients receiving NB‐UVB treatment until 31/12/2002 in Tayside, Scotland, were accessed from a treatment database and linked to the Scottish Cancer Registry. Indirect standardization was used to compare skin cancer incidence in the study population with age and sex matched cancer registry data for the Tayside population. We also assessed the effect of NB‐UVB exposure treatment numbers on the risk of developing skin cancer. Results  Of 4690 records reviewed, 4665 were suitable for analysis with 3886 records linked with the cancer registry and 3867 followed‐up for at least 6 months before 31/12/02 (the date at which cancer registration was deemed to be complete). The median number of NB‐UVB treatments was 29 with 352 patients receiving ≥ 100 treatments. The study gave 24 753 person‐years of follow up. First skin cancers recorded in study patients were 27 basal cell carcinomas (BCC), seven squamous cell carcinomas (SCC) and six melanomas. No association was found between NB‐UVB exposure alone (without PUVA) and any skin cancer. For NB‐UVB and PUVA treated patients there was an association with BCC, with 27 BCCs found compared with 14·1 expected in the matched population. Conclusion  We found no significant association between NB‐UVB treatment and BCC, SCC or melanoma. There was a small increase in BCCs amongst those also treated with PUVA. These reassuring results do not demonstrate the early increase in skin cancers that was found associated with PUVA treatment. However, cautious interpretation is required as the cohort contained relatively few patients who had a high treatment number and because the slow evolution of skin cancers may result in a delayed incidence peak. Ongoing risk assessment is therefore essential.     

Identification of nail features associated with psoriasis severity

There are no detailed studies of the prevalence of nail psoriasis and clinical characteristics of psoriatic nail involvement, including nail features associated with disease severity. Therefore, we designed a study to investigate the prevalence and characteristics of psoriatic nail involvement in patients with psoriasis and determine the relationship between psoriatic nail features and severity of nail psoriasis and cutaneous psoriasis. The Nail Psoriasis Severity Index (NAPSI) was used for evaluation of the severity of nail lesions. The presence of nail fold psoriasis (NFP) was also assessed. The severity of psoriasis was evaluated by calculating the Psoriasis Area and Severity Index (PASI). As a result, the prevalence of nail psoriasis was 85.5%. Pitting was the most common clinical feature (55.6%). The severity of nail psoriasis was not affected by medical parameters, although patients with localized pustular psoriasis tended to have more severe nail psoriasis than did those with chronic plaque psoriasis. When comparing the mean NAPSI and the mean PASI according to nail lesions, we found that subungual hyperkeratosis (SH) and NFP were significantly associated with the severity of both nail psoriasis and cutaneous psoriasis. Psoriatic nail changes were most common in the first digit. Conclusively, the majority of patients with psoriasis had psoriatic nail involvement, and Koebner's response seems to be closely related to the induction of nail psoriasis. To limit progression of the disease, psoriatic patients with SH or NFP should be examined thoroughly because those clinical features reflect the levels of severity of both nail and cutaneous psoriasis.     

窄谱中波紫外线不同照射剂量治疗寻常性银屑病临床疗效观察

目的：观察311nm窄谱中波紫外线（NB—UVB）不同照射剂量以及维持照射治疗寻常性银屑病的疗效及安全性。方法：采用半身、单盲、不同照射剂量方案治疗25例寻常性银屑病患者．回顾性分析维持照射以及不干预方案对银屑病复发的影响。结果：92％的患者银屑病皮损面积和严重度指数（PASI）评分改善率〉75％;大剂量方案起效较快;低增量方案的平均累积剂量较低,平均治疗次数较多,平均治疗费用也较高;维持照射以及不干预方案对于患者1年后的复发率无明显影响。结论：NB—UVB治疗寻常性银屑病疗效好、不良反应小;低增量方案有望在取得满意疗效的同时降低紫外线治疗的潜在风险;对已取得满意疗效的银屑病患者不建议采用维持光疗方案。     

Comparison of phototherapy with near vs. far erythemogenic doses of narrow-band ultraviolet B in patients with psoriasis

The therapeutic effectiveness of radiation from a 311 nm ultravoilet B (UVB) lamp (Philips TL-01) in a near vs. far erythemogenic therapy regimen was investigated in 13 patients with widespread, symmetrically distributed psoriasis. The patients received UV therapy starting with 70% of the 311 nm minimal erythema dose (MED) on one randomly chosen half of the body and 35% of the 311 nm MED on the other half. Therapy was given three to five times a week, and the UVB dose in both regimens was increased simultaneously in the same relation. For the 11 patients completing the study, the mean psoriasis area and severity index (PASI) score for the near vs. far erythemogenic treatment side was 21.2 vs. 18.5 before therapy (Wilcoxon's test, not significant), 11.8 vs. 14.4 at week 1 ( P  = 0.003), 8.2 vs. 12.0 at week 2 ( P  = 0.004), and 6.6 vs. 15.6 at week 3 ( P  = 0.005). After 3 weeks, a satisfactory response (i.e. improvement of the initial PASI score by more than 75%) was observed in six of 11 patients on the near erythemogenic treatment side vs. three of 11 patients on the far erythemogenic side. However, the definitive median total number of treatments needed to achieve a satisfactory therapy response on the near vs. far erythemogenic sides was 12 vs. 16 ( P  = 0.022), whereas the definitive median cumulative UV dose was 14.0 vs. 9.1 J/cm² ( P  = 0.088), respectively. These results suggest that near erythemogenic 311 nm UVB therapy may clear psoriasis faster than far erythemogenic therapy but that the latter regimen may be equally effective as it requires slightly more treatment sessions at a lower (and possibly less carcinogenic) cumulative UV dose.     

Remission period in psoriasis after multiple cycles of narrowband ultraviolet B phototherapy

The aim of this study was to investigate the duration of remission periods in psoriasis after narrowband ultraviolet B (NB‐UVB) phototherapy, especially during multiple cycles of treatment. We analyzed 63 patients (101 cases) demonstrating marked improvement after NB‐UVB phototherapy. The remission period was defined as the duration of time from the end of phototherapy until treatment using either phototherapy or systemic treatments was required again. It was found that an age of 60 years or older, history of systemic therapy within 6 months and three or more phototherapy cycles were significantly associated with shorter remission periods. Furthermore, multivariate analysis confirmed that three or more phototherapy cycles (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.73–9.33; P = 0.001) and a history of systemic therapy (OR, 2.2; 95% CI, 1.27–3.95; P = 0.005) were independently associated with the shorter remission period. In conclusion, when planning NB‐UVB phototherapy for psoriatic patients who have undergone multiple phototherapy cycles, clinicians should consider the possibility of shorter remission periods.