Acantholytic dyskeratotic epidermal naevus in a patient with guttate psoriasis on PUVA therapy

A 79-year-old male with psoriasis developed a zosteriform acantholytic dyskeratotic epidermal naevus during PUVA therapy. The eruption was successfully treated with etretinate 0.75 mg/kg/day and a subsequent course of PUVA with the affected area covered prevented a recurrence of the naevus.     

Extracorporeal photochemotherapy as an effective treatment modality in chronic graft-versus-host disease

Background In chronic graft-versus-host disease (cGvHD) cytotoxic and suppressor T lymphocytes probably play a decisive pathogenetic role. The efficacy of conventional immunosuppressive therapy is often insufficient, and drug side effects may produce further complications. Photochemotherapy with orally administered photosensitizer 8-methoxypsoralen (8-MOP) followed by UV-A irradiation of the skin (PUVA) has been reported as an advantage. Extracorporeal photochemotherapy (ECP) was introduced as an improved method of photochemotherapy compared with PUVA. ECP selectively affects autoreactive as well as malignant T lymphocytes and implies repeated ex vivo UV-A irradiation of chemically photosensitized leukocytes, followed by reinfusion. The treatment efficacy depends essentially on sufficient plasma levels of 8-MOP. In cases of considerable gastrointestinal malabsorption, however, therapeutic levels of 8-MOP are rarely achieved when the drug is administered orally. Objective In a case of severe cGvHD, ECP was used because of disease progression, despite massive conventional immunosuppressive therapy. Patient and method After bone marrow transplantation a 13-year-old girl developed acute Gv HD, which turned later to severe c Gv HD with massive involvement of the skin, oral mucosa, liver and gastrointestinal tract. The treatment with prednisolone, cyclosporin A (Cs A), azathioprine and thalidomide was without success. When the patient was 15 we started ECP with individually adapted modifications. Especially because of severe gastrointestinal malabsorption, a liquid preparation of 8-MOP was administered directly into the leukocyte (buffy coat) fraction, received by leukapheresis. Results After 15 treatment cycles within 12 months immunosuppressive drugs were omitted because of noticeable improvement in cutaneous changes, liver function parameters and general condition (Karnofsky score 85–90% compared with 30–40% at the beginning). Conclusion It seems to us that this modification of ECP is a very effective and safe treatment modality for cGvHD without any side effects.     

Trioxsalen bath plus UVA effective and safe in the treatment of psoriasis

Seventy-four patients with psoriasis were treated using a trioxsalen bath (50 mg/150 1 of water) and long wave ultraviolet light (UVA) given in an ordinary PUVA-cabin. Good or excellent results were observed in 92% of the patients in the initial phase and in 63% during the maintenance treatment. Because of local side-effects the therapy was discontinued in two patients. One of them developed contact hypersensitivity to trioxsalen and the other developed blisters with such low doses of UVA that it was difficult to maintain the proper dose. The therapy was started with 0-28 J/cm² of UVA and after an average of 18 treatments, when the average dose was 1.70 J/cm², the patients were moved to maintenance treatment which took place at 1-4 week intervals. The therapy was well tolerated and cosmetically very acceptable. The final tan was even on all but the face, which remained untanned.     

HLA-C and guttate psoriasis

BACKGROUND: Psoriasis is a heterogeneous disease in its clinical expression. Both genetic and environmental factors are thought to contribute to the pathogenesis of the inflammatory and hyperproliferative components of the typical skin lesions. Predisposing genetic influences include associations with human leucocyte antigens (HLA) of which that with HLA-Cw6 is the strongest. Guttate psoriasis is a specific clinical manifestation of psoriasis frequently associated with group A beta-haemolytic streptococcal throat infection. OBJECTIVES: We set out to determine whether further clinical subdivision of psoriasis is associated with tighter correlation with HLA-C alleles. PATIENTS/METHODS: We determined the HLA-C locus genotype of 29 caucasian patients with guttate psoriasis presenting consecutively with guttate psoriasis associated with a history of a sore throat and/or an antistreptolysin O titre > 200 IU mL-1. Polymerase chain reaction typing using sequence-specific primers was used to detect all known HLA-C alleles. These data were compared with a control population of 604 random caucasian cadaver donors. RESULTS: All patients (100%) with guttate psoriasis carried the Cw*0602 allele compared with 20% of the control population (odds ratio = infinity; 95% confidence limits 25.00-infinity; Pcorrected < 0.0000002). CONCLUSIONS: This result is consistent with HLA-Cw*0602 playing a part directly in the pathogenesis of guttate psoriasis.     

PUVA treatment of psoriasis in the United Kingdom

Information concerning the operation of 134 PUVA units in 96 dermatology centres in the U.K. was collected by a postal questionnaire. The most common protocol was to give PUVA three times weekly in the treatment of psoriasis, and to choose the initial dose of UVA according to skin type. However, the initial UVA dose encompassed a range of five or more within each skin type.     

Antistreptococcal treatment of guttate psoriasis: a controlled study

Background  The role of streptococcal infection in the initiation of guttate psoriasis is well-recognized. But the treatment results with oral erythromycin and phenoxymethylpenicillin are conflicting.
Objective  Our purpose was to evaluate the effectiveness of these antibiotics in the treatment of streptococcus associated guttate psoriasis comparing with a control group.
Methods  A total of 43 male patients with serologic evidence of a recent streptococcal infection were studied. Their mean age was 21 years (ranged between 19 and 23 years). These 43 patients were randomly allocated into three groups (no treatment group n  = 15, erythromycin group n  = 14, phenoxymethylpenicillin group n  = 14). Both the treatment groups were treated for 14 d. All the groups were followed up for additional 4 weeks.
Results  There were no statistically significant improvement in any group and among the groups.
Conclusion  There was no statistically significant improvement in streptococcus associated guttate psoriasis with or without a course of oral penicillin or erythromycin.     

Granulomatous secondary syphilis coinciding with PUVA treatment in a patient with psoriasis: an apparent failure of PUVA therapy

A 39-year-old man is described who has been suffering from psoriasis for many years. Because of the extensive involvement of the skin he was treated with PUVA therapy, initially with a good result. A second course of PUVA treatment was unsuccessful. Histopathological examination of the (persisting) skin lesions at this time showed clear granulomatous infiltration, in addition to psoriatic changes. Based on history, serological and dark-field examination, a secondary syphilis was diagnosed. The possible influence of PUVA therapy is discussed.     

Winnie the Pooh and psoriasis too: an isomorphic response of guttate psoriasis in a tattoo

Abstract:  Since Koebner's first observance of the isomorphic response of psoriasis in a tattoo in 1872, a paucity of written reports has appeared in the literature describing this phenomenon, although it appears to be common knowledge among dermatologists. We report a strep-induced guttate psoriasis isomorphic response in a Winnie the Pooh tattoo in a 19-year-old.     

Immunoblotting of streptococcal antigens in guttate psoriasis

Guttate psoriasis may be precipitated by acute streptococcal infection, usually of the upper respiratory tract. We have studied the immune response to streptococci in 26 patients presenting with a first or recurrent episode of acute guttate psoriasis (AGP), using immunoblotting. Eighteen of 26 patients studied had a demonstrable response to a wide range of streptococcal antigens using this approach, compared with 14 of 26 patients who demonstrated a response using more conventional anti-streptococcal antibody tests. Patients with AGP had a significantly higher antibody detection score using immunoblotting than did control subjects (P<0.005). We conclude that immunoblotting is a useful technique in studying this condition and may be of benefit in exploring the immunopathogene-sis of AGP.     

Atypical psoriasis of the face and hands after PUVA treatment

In sixty patients with psoriasis, two types of lesions developed after repeated and prolonged courses of PUVA radiation. In sixteen patients, new lesions on the face resembled seborrhoeic dermatitis; in thirteen patients thick plaques on the dorsum of the hands developed insidiously over the years. There was no significant association between the two types of lesions and only the latter were dose-related. The appearance of recalcitrant psoriasis on the face and hands appears to be a complication of PUVA treatment.