Comparison of therapeutic efficacy of topical PUVA, oral etretinate, and combined PUVA and etretinate for the treatment of psoriasis and development of PUVA lentigines and antinuclear antibodies

Sixty-two and 38 psoriatic patients were treated with topical PUVA and combined etretinate and topical PUVA (Re-PUVA), respectively. In both groups, 50% of the patients showed initial recovery after 6 weeks and over 90% after 14 weeks. Re-PUVA was more effective than PUVA alone in obtaining complete clearance (p<0.05). To clear psoriasis in 50% of the patients, PUVA and Re-PUVA required 63 and 26 weeks, respectively. Furthermore, the integrated clearance rates after 70 weeks were 50% in PUVA and 63% in Re-PUVA. Each therapy showed a similar remission period; psoriasis recurred in 50% of the patients after 4 months. In addition, 17 patients were treated with oral etretinate, and Re-PUVA was found to be more effective than etretinate monotherapy. Another aim was to determine whether etretinate would inhibit the development of PUVA side effects. Adding etretinate failed to inhibit the production of PUVA lentigines but clearly suppressed antinuclear antibody (ANA) expression. Six of 56 patients treated with PUVA alone developed ANA during the treatment. In marked contrast (p=0.05), ANA was detected in none of 34 patients treated with Re-PUVA.     

Combination of photochemotherapy (PUVA) and ultraviolet B (UVB) in the treatment of psoriasis vulgaris

Nineteen patients with psoriasis vulgaris were treated with a combination of psoralen-ultraviolet A (PUVA) and ultraviolet B (UVB) on the right side of their bodies and with PUVA therapy alone on the left side. Herein is an analysis of the results. There were no significant differences in the mean number of treatments, the mean UVA dose at clearing, or the mean cumulative UVA dose between the PUVA-UVB side and the PUVA side. However, in 4 cases, the PUVA-UVB side cleared more rapidly than the PUVA side. Interestingly, patients who received PUVA-UVB on one side and PUVA on the other required fewer treatments, a lower ultraviolet (UV) dose at clearing, and a lower cumulative UV dose than did patients who were treated with only PUVA monotherapy or UVB monotherapy, following the same protocol. This combined method may be useful in the treatment of chronic psoriatic patients, because of rapid clearing and a marked reduction in the total cumulative UV radiation. However, further follow-up studies are indicated due to the long-term side effects of combined UV radiation.     

Topical PUVA, etretinate, and combined PUVA and etretinate for palmoplantar pustulosis: comparison of therapeutic efficacy and the influences of tonsillar and dental focal infections

Twenty patients with palmoplantar pustulosis (PPP) were treated with topical PUVA, oral etretinate (Re), or combined PUVA and etretinate (Re-PUVA). Re and Re-PUVA treated sites improved and/or cleared more rapidly than PUVA treated sites. Complete clearance was observed in six of ten sites treated with Re-PUVA, two of ten with Re, and one of ten sites with PUVA within 12 weeks. UVA-control sites failed to be cleared within 12 weeks. Remission periods after stopping the treatment were 1.5 +/- 0.5 weeks (n = 2) with Re, 10.5 +/- 11.4 weeks (n = 6) with Re-PUVA, and one year (n = 1) with PUVA. These results overall suggested that Re-PUVA is the most effective treatment for PPP. Tonsillar focal infection (TFI) and dental focal infection (DFI) were found in 6/20 and 17/20 patients, respectively. However, the presence of focal infection (FI), TFI and/or DFI, did not appear to interfere with the therapeutic activities of Re and/or PUVA, because the complete clearance rates and remission periods in FI(+) patients were comparable with those in FI(-) patients.     

口服阿维A结合光化学疗法治疗寻常型银屑病临床疗效观察

目的：评价口服阿维A结合光化学疗法治疗寻常型银屑病的疗效及不良反应。方法：60例寻常型银屑病患者随机分为两组，分别给予单一光化学治疗、口服阿维A及光化学治疗。结果：口服阿维A结合光化学治疗的疗效显著优于单一光化学治疗，长波紫外线的总暴露量可明显减少，可缩短近一半疗程。结论：口服阿维A结合光化学疗法是一种值得推广职至重度寻常型银屑病的方法。     

改良PUVA疗法治疗慢性斑块性银屑病疗效分析

目的：探索用改良PUVA疗法治疗慢性斑块性银屑病的疗效和安全性。方法：67例寻常型银屑病患者口服8-MOP0．6mg/kg后照射UVA和UVB，每周3次，共治疗8周，用PASI积分评价疗效，并记录不良反应。结果：治疗开始2-4周后出现疗效，随着治疗时间的延长，PASI总积分逐渐下降，有效率逐渐提高，在治疗结束时痊愈率达到96．5％，有效率达100％。27例患者(40．3％)出现不良反应，绝大多数为轻度，没有因不良反应停止治疗的病例。结论：改良PUVA疗法治疗慢性斑块性银屑病具有良好疗效和安全性。     

Severe oral lichen planus: treatment with an aromatic retinoid (etretinate)

A double-blind study of twenty-eight patients with severe oral lichen planus treated with etretinate (75 mg daily) or a placebo for 2 months, showed that the oral retinoid had a marked beneficial effect. Nine non-responders who had received only placebo then entered an open cross-over study and they responded well to etretinate. Etretinate thus provided effective symptomatic relief for severe oral lichen planus, but side-effects were common, and six patients stopped treatment because of them.     

Effects of oral retinoid on the SDS-PAGE profile of stratum corneum keratin in patients with psoriasis

α-Keratins from horny cells of lesional and non-lesional skin in psoriatic patients were examined by sodium dodecylsulfate polyacrylamide gel electrophoresis before and after oral retinoid (etretinate at a dose of 50 mg/day) treatment. Horny cell specimens were obtained from lesional, non-lesional, and normal human skin of the back or thigh by scraping with scalpel and/or tape stripping before retinoid treatment. Horny cell specimens of healed-lesional skin and retinoid-affected skin were obtained by tape stripping because the horny cell layer was too thin to use a scalpel. α-Keratins from lesional horny cells showed 3 major polypeptide bands with molecular weights (mw) of 53,000, 55,000, and 59,000 and some minor bands with mw of 62,000, 66,000, and less than 53,000. Non-lesions showed two polypeptides (mw, 59,000 and 66,000) before treatment. After treatment, α-keratins from horny cells of both non-lesions and resolved lesions showed three polypeptides bands (mw, 59,000, 62,000, and 66,000).     

NB-UVB联合8-MOP PUVA治疗小腿斑块状银屑病疗效评价

目的: 评价NB-UVB联合8-甲氧补骨脂素（8-MOP） PUVA治疗斑块状银屑病的疗效。方法: 分别对16例银屑病患者双侧小腿进行PASI评分,一侧给予NB-UVB照射,另一侧给予NB-UVB联合8-MOP PUVA,每周3次,共治疗20次。结果: NB-UVB治疗侧治疗前后PASI评分分别为8.21±2.97和2.31±1.01,差异有统计学意义(P＜0.05);NBUVB联合8-MOP PUVA治疗侧分别为8.33±2.54和1.20±0.93,差异有统计学意义(P＜0.05)。治疗后NBUVB联合8-MOP 治疗侧较NB-UVB治疗侧PASI更低,差异有统计学意义(P＜0.05)。结论：NB-UVB联合8-MOP PUVA可明显促进小腿顽固部位皮损的消退。     

Therapy of psoriasis with retinoid plus PUVA: Clinical and histologic data

Summary In a group of 40 patients suffering from wide-spread psoriasis oral administration of a retinoid (Ro 10-9359) was followed by PUVA therapy. The clearance rate was increased by 30% as compared to PUVA alone. Except for cheilitis no side effects were seen. Histological analysis in 20 patients before, during and after therapy revealed an intensification of psoriatic tissue changes after retinoid treatment. Loss of corneal layers, massive exoserosis, and neutrophil migration were prominent features. Mitotic counts were not increased by the pretreatment. The increased susceptibility of diseased skin to PUVA as produced by this drug appears to be based on several factors related to the tissue changes revealed by histology.Presented at the Niels-Stenson-Symposion, Appenrade, Denmark, October 28, 1978     

阿维A酯和(或)阿维A治疗儿童脓疱型银屑病

采用阿维A酯与阿维A治疗13例儿童脓疱型银屑病,其中用阿维A酯治疗7例,用阿维A治疗5例,另有1例患儿首次用阿维A酯治疗,4年后改用阿维A治疗。起始剂量为0.3～1mg/(kg·d),病情控制后每2周减量1次,维持剂量为0.1～0.2mg/(kg·d),疗程为2个月。阿维A酯有效率为77.8%,阿维A为83.3%,用药后7～8d体温下降、无新发脓疱出现。最常见的不良反应有口干、唇干,全身皮肤干燥及瘙痒。治疗结果表明阿维A酯与阿维A治疗儿童脓疱型银屑病疗效相近,且停药无反跳现象,可在实验室定期监测下作为首选药物。     

Phototherapy and PUVA photochemotherapy in children

The use of phototherapy and photochemotherapy in children has been limited due to concerns over their long-term carcinogenic potential. Furthermore, the method of administration is disconcerting to some children, particularly as phototherapy treatment units are seldom rendered 'child-friendly'. Despite these reservations, ultra-violet therapies can be useful treatment options for children with selected dermatological conditions provided they are used under carefully controlled conditions.     

Large increments in psoralen-ultraviolet A (PUVA) therapy are unsuitable for fair-skinned individuals with psoriasis

The ideal psoralen-ultraviolet A (PUVA) regimen for chronic plaque psoriasis has yet to be established. There are four components to a PUVA regimen: the dose of psoralen, the starting dose of UVA, the frequency of treatment and the incremental UVA dose protocol. Recent studies have been directed at trying to optimize the efficacy of PUVA while minimizing acute side-effects and the risk of cutaneous carcinogenesis, believed to be independently related to the cumulative dose of UVA and the total number of treatments. The British Photodermatology Group recommends two twice-weekly PUVA regimens: one starts with 50% of the minimal phototoxic dose (MPD) and uses weekly increments of 40%, 30%, 25%, 20%, 15%, 10% and 5% of the previous dose to a maximum of 14.5 J/cm2; the other starts with a fixed dose based on skin type and uses weekly dose increments of 40%, decreasing to 20% once erythema develops. We undertook a prospective randomized controlled trial comparing these regimens in 85 Irish patients. The clearance rate with the MPD regimen was lower than with the skin type regimen, 67.5% vs. 95% (P < 0.05). The reasons for treatment failure were grade 3 erythema and severe PUVA itch. There was a trend suggesting that patients with skin types I and II, but not skin type III, required a higher cumulative UVA dose and fewer exposures to clear with the MPD regimen than the skin type regimen, although this did not reach statistical significance. Grades 2 or 3 erythema were very common in both treatment groups (52. 5% of the skin type group and 45% of the MPD group). This is the third study to suggest that patients with skin types I and II receive a higher total UVA dose when the starting dose is 50-70% of the MPD (rather than 0.5 J/cm2 for skin type I and 1.0 J/cm2 for skin type II) and when large dose increments are used. We suggest that smaller dose increments should be used in patients with skin types I and II.     

补骨脂素长波紫外线和窄谱中波紫外线治疗寻常性银屑病临床疗效观察

目的:观察补骨脂素长波紫外线(PUVA)和窄谱中波紫外线(NB-UVB)治疗寻常性银屑病的临床疗效及其影响因素。方法:分别采用PUVA和311nmNB-UVB照射治疗146例寻常性银屑病患者,并以银屑病面积和严重度指数(PASI)评价疗效,分析照射剂量等对疗效和复发的影响。结果:NB-UVB治疗寻常性银屑病的疗效与PUVA相当,NB-UVB组患者的治疗时间明显短于PUVA组,NB-UVB组患者1年内复发率高于PUVA组。结论:NB-UVB治疗寻常性银屑病与PUVA相比,不良反应较少,起效较快。     

Combination therapy in the treatment of psoriasis

In addition to topical monotherapy for mild and systemic monotherapy for moderate to severe psoriasis, combination therapy plays an important role in daily practice. Although clinical trials almost exclusively evaluate monotherapy regimens, in real life psoriasis patients are usually treated with combination therapies. All combinations are used, topical/topical, topical/UV‐light, topical/systemic or UV‐light/systemic. Often not only two but more drugs/therapies are combined. Not every combination provides additive or synergistic effects. Some combinations are not possible and may be regarded as contraindications. Data on a benefit‐risk‐assessment are much more sparse in medical literature as compared to monotherapies. We summarize current knowledge about the use of combination therapies in psoriasis on the basis of published literature in the form of a table to show which combinations are possible, useful or which can not be recommended. This provides a quick overview of available options.     

Twice- vs. thrice-weekly MPD PUVA in psoriasis: a randomized-controlled efficacy study

BACKGROUND: Oral psoralen-ultraviolet A (PUVA) has been the treatment of choice of moderate to severe forms of psoriasis, however there is no standardized worldwide protocol. Twice- and thrice-weekly regimens had been used. In this study we compare the efficacy of these regimens. METHODS: Two PUVA regimens in 28 patients with clinical diagnosis of psoriasis, with symmetric and no less than 20% of body surface area involvement, using a half-body study, were compared. Each patient body half was randomized to receive either twice- or thrice-weekly PUVA. A blinded trained dermatologist assessed the PASI score in each body half at the beginning of the study and at clearance or after 25 sessions. RESULTS: Twenty-three patients completed the study. There were no significant differences in the efficacy of both treatments considering the median percentage of PASI decrease (92.9% for the body half with the twice-weekly regimen and 94.8% for the thrice-weekly treatment, P=0.179). There were significant differences comparing the median number of sessions needed for clearance and the median cumulative doses, favouring the twice-weekly regimen (15 vs. 22, P=0.000, and 142.5 vs. 241.4 J/cm(2), P=0.001, respectively). CONCLUSION: The treatment of psoriasis patients with twice- or thrice-weekly PUVA in this study was equally effective, the number of sessions required and the cumulative doses of UVA were lower with the twice-weekly regimen.     

Antinuclear antibodies and oral methoxsalen photochemotherapy (PUVA) for psoriasis.

In view of theoretical concern that psoralen ultraviolet A radiation (PUVA) therapy might induce a systemic lupus erythematosus-like syndrome, we studied serum antinuclear antibodies (ANAs) in patients with psoriasis who received PUVA and are participating in a five-year prospective study. At 14 centers, 1,023 patients had two or more ANA determinations. When first and last tests were compared, the incidence of positive tests for ANAs was not significantly different (P greater than .2). In addition, there was no apparent relationship between the frequency of PUVA treatments and the probability of a positive test. Over a two-year period, there is no evidence to indicate that PUVA therapy for psoriasis has resulted in a significantly higher number of positive tests for ANAs within our population.     

A clinical evaluation of the effects of an aromatic retinoid (Tigason), combination of retinoid and PUVA, and PUVA alone in severe psoriasis

Eighty ambulatory adult patients with severe psoriasis were included in our 14-week study to compare the clinical effects of treatment with an aromatic retinoid (Tigason), combination treatment with aromatic retinoid plus PUVA (RePUVA), and PUVA alone. RePUVA was given by two different modifications: either 4 weeks of pretreatment with retinoid followed by 6 weeks of PUVA treatment, or 10 weeks of retinoid treatment with concomitant PUVA treatment during the last 6 weeks. The latter modification of RePUVA proved to be significantly more effective than the other treatments (P<0.01) as regards complete remission. With respect to the number of patients with good or excellent improvement (75–100% improvement) there was no marked difference between RePUVA and PUVA treatments. Retinoid alone proved to be the least effective, showing, however, a good to excellent result in 65% of patients. Besides the increase in efficacy, another advantage achieved by RePUVA was a highly significant (P<0.001) reduction of total UVA doses to about one third as compared to PUVA therapy.