Psoralen–ultraviolet A vs. narrow-band ultraviolet B phototherapy for the treatment of vitiligo

BACKGROUND: Although many treatment modalities have been tried for the treatment of vitiligo, none is uniformly effective. Psoralen phototherapy (psoralen ultraviolet A (PUVA)) is established as efficacious treatment for vitiligo. Recently, narrow-band UVB (NBUVB) has been reported to be an effective and safe therapeutic option in patients with vitiligo. OBJECTIVE: To compare the efficacy of PUVA and NBUVB in the treatment of vitiligo. DESIGN AND SETTING: Retrospective analysis of 69 patients with vitiligo who were treated either with PUVA or NBUVB at the pigmentary clinic of the Dermatology Department of the Postgraduate Institute of Medical Education and Research, Chandigarh, India. OUTCOME MEASURES: The following variables were compared between the two groups of patients: repigmentation status, number of treatments for marked to complete repigmentation in existing lesions, appearance of new lesions or increase in size of existing lesions, adverse effect of therapy, stability of repigmentation and colour match. RESULTS: In PUVA-treated group, 9 patients showed marked to complete repigmentation (23.6%) and 14 patients showed moderate improvement (36.8%), whereas in NBUVB-treated group, 13 patients showed marked to complete repigmentation (41.9%) and 10 patients showed moderate improvement (32.2%). A statistically significantly better stability and colour match of repigmentation with surrounding skin was seen in NBUVB-treated patients. CONCLUSION: We showed that NBUVB is more effective than PUVA and repigmentation induced with NBUVB is statistically significantly more stable.     

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.     

Local narrowband UVB phototherapy vs. local PUVA in the treatment of chronic hand eczema

BACKGROUND: Hand eczema is a chronic skin disorder characterized by a poor response to conventional therapies. Although local PUVA has been proven to be effective in the treatment of chronic hand eczema, little is known about the efficacy and safety of local narrowband UVB (TL-01) for this condition. The aim of our study was to compare the efficacy and safety of local narrowband UVB phototherapy with paint-PUVA in patients with chronic hand eczema of dry and dyshidrotic types unresponsive to conventional therapies. PATIENTS/METHODS: Fifteen patients (nine men and six women) with chronic hand eczema of dry and dyshidrotic types was included in this prospective, comparative study based on a left to right comparison pattern. The treatments were administered with local narrowband UVB irradiation on one hand and local paint-PUVA using 0.1% 8-methoxypsoralen gel on the other hand three times a week over a 9-week period. The NB-UVB irradiation was administered using a local NB-UVB system equipped with TL-01 lamps. The initial dose was 150 mJ/cm(2) for each patient. An increasing percentile dose schedule based on an increase of 20% was used in every session, until a final dose of 2000 mJ/cm(2) was reached. Evaluation of clinical scores was carried out every 3 weeks during the treatment period. RESULTS: Twelve of the 15 recruited patients completed the study. There was a statistically significant decrease in the mean clinical score at the third, sixth and nineth week in both groups. The difference in clinical response between the two treatment modalities was not statistically significant at the end of the 9-week treatment period. In the narrowband UVB-treated side, the tolerance of all the patients to the treatment was good all patients well-tolerated the treatment with the exception of mild xerosis that responded to topical emollients. CONCLUSION: Local narrowband UVB phototherapy regimen is as effective as paint-PUVA therapy in patients with chronic hand eczema of dry and dyshidrotic types.     

UVB 308‐nm excimer light and bath PUVA: combination therapy is very effective in the treatment of prurigo nodularis

Background Prurigo nodularis (PN) is a chronic inflammatory skin disease with nodular itching lesions. UV therapy – both PUVA and NUVB – are known to clear up PN temporarily due to the antipruritic effect of UV light. However, relapse after treatment is common in PN, which means that either long‐term therapy is necessary or the treatment protocols have to be optimized to minimize side‐effects. Objective The aim of this study was to evaluate the effect that combining bath PUVA and targeted UVB 308 nm excimer radiation has on recalcitrant nodular prurigo. Methods In a prospective trial, 22 patients with PN were treated with either PUVA alone or with a combination of PUVA and excimer UVB. The end point was complete or almost complete remission of PN. Results Adding a 308‐nm excimer UVB to the treatment of the pruritic nodules sped up the healing process; 30% less PUVA radiation was needed. Conclusion The combination of PUVA and excimer UVB in PN appears to be very efficacious. Reducing psoralen UVA doses by 30% offered long‐term benefits in phototherapy of chronic recalcitrant diseases like PN.     

Topical PUVA Therapy for Chronic Hand Eczema

Seventeen patients with persistent chronic hand eczema were treated with topical 0.1% 8-methoxypsoralen and UVA (PUVA) for 8 weeks. Significant improvement was achieved in 5 cases (29%), moderate improvement in 9 (53%), and little improvement in 3 (18%). The mean number of PUVA treatments was 22.2, and the mean total UVA dose was 63.5 J/cm². There was no association between clinical response and duration of hand eczema, positive patch test reaction, or atopic status. Since topical PUVA has no risk of systemic side effects, it should be considered as an alternative treatment for patients with chronic hand eczema who are resistant to other topical medications.     

Psoralen and ultraviolet A in the treatment of granuloma annulare

Background: Granuloma annulare (GA) is a benign, usually self‐limiting disease. Lesions may be localized or generalized with a tendency for generalized disease to follow a chronic course. There is evidence to support psoralen and ultraviolet A (PUVA) in the treatment of GA, but little data on long‐term benefits. The purpose of this study was to investigate the effect of PUVA in the treatment of GA, and to establish clearance and remission rates. Methods: We carried out a retrospective study of patients with generalized GA treated with PUVA over 13 years. Data were collected from case notes and a phototherapy database. On completion of treatment, outcome was assessed as clear, good improvement, moderate improvement and poor outcome. Follow‐up data were obtained for patients who had cleared using a postal questionnaire in addition to clinic notes. Results: Fifty per cent of courses resulted in clearance of disease, 16% in good improvement, 25% had moderate benefit and 9% had a poor outcome. Of the patients that cleared, 79% remained in remission at 6 months but only 32% were still clear 12 months following treatment. Conclusion: Our findings show clearance or good improvement of generalized GA in 66% of cases. Prolonged remission, however, occurred in less than a third of patients.     

Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema

Background: Both oral and bath PUVA with 8-methoxypsoralen (8-MOP) have been shown to be effective in the treatment of chronic palmoplantar eczema. However, most studies were retrospective and did not include longer follow-up periods.
Aim: To compare the therapeutic efficacy, tolerability and duration of remission after oral vs. bath PUVA using 8-MOP in patients with chronic palmoplantar eczema.
Methods: Twenty-nine patients were randomly allocated to treatment with oral or bath PUVA. Treatment was given thrice weekly for a maximum of 20 weeks. The primary outcome measure was the improvement in eczema score at the end of treatment. After clearing patients were followed up until relapse or up to 40 months.
Results: Overall, both PUVA modalities appeared comparably effective. However, after stratifying according to eczema type, significant differences in therapeutic outcome in general as well as in response to the two regimes were found. Dyshidrotic eczema responded better to both treatments ( P =0.048) and remained longer in remission than hyperkeratotic eczema. Hyperkeratotic eczema cleared significantly better with oral than with bath PUVA ( P =0.03).
Conclusion: Oral PUVA is preferable for patients with hyperkeratotic eczema and bath PUVA for patients with dyshidrotic eczema.     

Topical calcipotriene and narrowband ultraviolet B in the treatment of vitiligo

BACKGROUND: Treatment of vitiligo, despite significant advances made in the past few years, remains to be a challenge. Narrowband ultraviolet (NB-UVB) has emerged as an important therapeutic option for this condition. OBJECTIVE: To evaluate whether the combination of calcipotriene ointment and NB-UVB could enhance the efficacy of NB-UVB alone. METHODS: An open, bilateral comparison study was performed in 20 patients with symmetrical vitiligo between August 2001 and October 2002. All patients received NB-UVB three times per week. Calcipotriene ointment was applied to lesions on the left side of the body. Response was graded visually as significant (66-100% repigmentation), moderate (26-65%), mild (10-25%), and minimal (< 10%). RESULTS: Seventeen patients (six females, 11 males) completed the study. Eight patients (8/17=47%) had significant repigmentation after 67-180 treatments, six patients (35%), one patient (6%), and two patients (12%) had moderate, mild, and minimal repigmentation after 40-160, 57, and 14-21 treatments, respectively. Nine of the 17 patients had an appreciably better improvement on the NB-UVB and calcipotriene side by 29-114 treatments. In six of these patients, differences were still observed at the end of the study period. No side effects were noted. CONCLUSION: Combination therapy of topical calcipotriene and NB-UVB is a therapeutic option that could be considered in the management of patients with vitiligo.     

Lichen planus of the lower limbs: successful treatment with psoralen cream plus ultraviolet A photochemotherapy

Lichen planus (LP) classifies into different subtypes depending on morphology and localization. Localized LP of the lower limb (LPLL) manifests a great challenge due to persistent itching, therapeutic resistance and the risk to develop into SCC. We report two cases with LPLL refractory to standard topical therapy, which were successfully treated with psoralen cream plus UVA photochemotherapy (cream‐PUVA). We propose cream‐PUVA as an alternative therapeutic option effective for localized LP of the lower limbs.     

Variables in full‐body ultraviolet B treatment of skin diseases

Ultraviolet B (UVB) treatment is most often performed according to a fixed schedule, not necessarily considering important variables such as UV intensity, type of UVB source and skin pigmentation. These variables can rather easily be taken into consideration by the right choice of dosing unit. The advantage of going from dosing in time to Joule to standard erythema dose or to minimal erythema dose is considered. The size of most variables may be diminished considerably. Following these guidelines, it is possible to increase the efficacy of UVB phototherapy without increasing the risk of unintentional burning.     

窄谱UVB治疗寻常性银屑病的临床研究

目的　评价窄谱UVB治疗寻常性银屑病的疗效及安全性,并与改良PUVA(PUVA+UVB)疗法比较方法　108例患者,其中50例单纯照射窄谱UVB; 58例口服8 甲氧补骨脂素片, 0. 6mg/kg/次, 2h后照射UVA和UVB;每周3次,疗程8周,观察疗效与安全性。结果　经过8周治疗,窄谱UVB组基愈率为70. 0%,显效率为20. 0%。改良PUVA组基愈率为96. 6%,显效率为3. 4%;不良反应:窄谱UVB组仅个别患者出现轻度红斑、色素沉着及皮肤瘙痒。改良PUVA组发生率为40. 3%,多为轻中度消化道反应及皮肤瘙痒、色素沉着等。照射时间窄谱UVB组最长不超过7min,改良PUVA组最长需30min以上。结论　窄谱UVB治疗寻常性斑块型银屑病具有良好疗效,与改良PUVA疗法相比,虽然疗效略逊,但方法简便,患者无需服药,照光时间短,不良反应发生率亦低。     

NB-UVB治疗慢性湿疹疗效观察

目的探讨NB-UVB治疗慢性湿疹的临床疗效。方法治疗组以窄波UVB照射配合常规疗法;对照组只用常规疗法。结果治疗组有效率为89.47%,对照组为76.32%,两组比较差异有统计学意义(P<0.05)。结论窄波UVB治疗湿疹安全有效。     

Photo(chemo)therapy in private practice in Belgium, France and The Netherlands

Photo(chemo)therapy is used widely, and ultraviolet (UV) sources, protocols and indications are numerous. A survey was carried out to examine how photo(chemo)therapy is employed in private practice and to determine whether safety guidelines are respected. A questionnaire survey sent to Belgian, French and Dutch dermatologists generated 593 useful responses. UV sources, doses of UV and 8-methoxypsoralen (8-MOP), as well as the frequency of the treatment, were all different in the three countries. UV starting doses were rarely chosen according to the minimal phototoxic dose (MPD) or to the minimal erythema dose (MED). Total cumulative UV doses were not always determined. Maintenance PUVA therapy for psoriasis was still performed by 15 to 40% of dermatologists in the respective countries. Another striking fact was that genital protection is not universal. On the other hand, the irradiance of tubes is checked regularly, and contraindications are respected. Despite the availability of guidelines, clinicians seem to be inconstant in their assessment of the carcinogenic risk of UV radiation.     

Narrow band Ultraviolet B 311 nm in the treatment of vitiligo: two right-left comparison studies

AIM: Evaluation of narrow band ultraviolet B (NB UVB 311 nm) in the treatment of vitiligo by two independent studies. The first study compared NB UVB with a well-established therapeutic modality, psoralen ultraviolet A (PUVA), and the second study was conducted to find out whether psoralen might add to its efficacy. METHODS: In the first study, 15 patients were exposed on the left half of their body to UVB 311 nm and then exposed on their right half to UVA after ingestion of psoralen. In the second study, 20 patients were exposed to UVB 311 nm on the left side of the body, followed by ingestion of psoralen and exposure to NB UVB 311 nm 90 min later to the right side of the body. In both studies, while exposing one side, the other was protected by an UV-proof gown. Thus two right-left comparative studies were carried out simultaneously, namely: UVB 311 nm vs. PUVA and UVB 311 nm vs. PUVB 311 nm. RESULTS: In the first study, comparison of PUVA and NB UVB 311 nm showed no difference either in the degree of response or in the incidence of complications. In the second study, comparison of PUVB and UVB showed equal clinical improvement on both sides. The cumulative dose needed to achieve the same response on the PUVB side was lower than that on the UVB side, but the difference was not statistically significant. The incidence of phototoxic reactions was significantly higher on the PUVB treated body half. CONCLUSION: NB UVB 311 nm has similar repigmentary effects as PUVA. The addition of psoralen does not increase its efficacy.     

Morphological changes in the proximal area of the rat's hair follicle during early catagen

Summary In human adult volunteers, oral 8-methoxypsoralen and UVA (PUVA) caused an almost linear dose-response effect in depleting adenosine triphosphatase positive epidermal Langerhans cells (LC) when irradiations of 1–5 J/cm² were used. A higher dose did not appreciably augment the LC depleting effect although the intensity of the PUVA-induced skin inflammation increased. After a single PUVA dose of 5 J/cm², a nadir in LC density was achieved on day 8 after irradiation, with a decrease from the starting mean count of 704 ± 58 cells/mm² to 195 ± 173 cells/mm². On day 15 after irradiation, the LC count was still low (261±249 cells/mm²). In comparison, a single erythematogenic irradiation with a medium-pressure mercury lamp emitting mainly UVB caused an LC depletion which was less intensive, peaked earlier and was almost completely restored by day 15. With both modalities morphological changes were induced in the LC, manifested initially as a shortening of the dendritic processes and later as cell enlargement and dendrite elongation.     

Survey of phototherapy practice by dermatologists in Australia

A postal survey was sent to all dermatologists in Australia to determine current phototherapy practices. Questionnaires were returned by 158 (57%) of 277 dermatologists, of whom 112 (71%) provided phototherapy. Large variations existed in attitudes and practice, including indications, contraindications, dosage schedules, equipment maintenance, response to adverse events, and follow-up arrangements. Cumulative ultraviolet (UV) doses for psoralen and UVA (PUVA) were not calculated by 21%, while 30% did not calculate cumulative doses for UVB. Written informed consent was not obtained by 32%. Phototherapist dermatologists reported 25 patients developing melanoma following PUVA. Only 30% of Australian dermatologists organize regular follow up of patients after phototherapy. Australians have the highest rates of melanoma and non-melanoma skin cancers in the world, because of their ancestry and high solar exposure. This makes it inappropriate for Australian dermatologists to rely entirely on foreign safety data when assessing the risks and benefits of phototherapy in Australian patients. There is a need for standardized Australian guidelines that can be prospectively assessed to ensure phototherapy is used to maximize efficacy and minimize risks in Australian patients, given their unique ancestral mix and outdoor lifestyle.