Guidelines for bath PUVA, bathing suit PUVA and soak PUVA.

BACKGROUND: The aim of these guidelines is to encourage dermatologists to use bath psoralen plus ultraviolet A (PUVA), bathing suit PUVA and soak PUVA in the treatment of psoriasis vulgaris and other conditions. METHODS: Evidence was collected using searches of the PubMed, MEDLINE and COCHRANE databases using the keywords "bath PUVA," "soak PUVA," "bathing suit PUVA" and "turban PUVA." Only publications in English were reviewed. RESULTS: One hundred and thirty-eight studies were evaluated, 57 of which fulfilled the criteria for inclusion. CONCLUSIONS: Both bath PUVA and bathing suit PUVA are very effective and safe treatments for generalized stable plaque psoriasis (strength of recommendation, A). Soak PUVA is very effective in the treatment of both palmoplantar psoriasis and chronic palmoplantar eczema (strength of recommendation, A).

Análisis retrospectivo del papel de la fototerapia en la enfermedad injerto contra huésped crónica cutánea. Revisión de la literatura / The Role of Phototherapy in Cutaneous Chronic Graft-vs-Host Disease: A Retrospective Study and Review of the Literature

INTRODUCCIÓN Y OBJETIVOS: La enfermedad injerto contra huésped (EICH) crónica cutánea es una complicación frecuente tras un trasplante de progenitores hematopoyéticos. La fototerapia es una modalidad terapéutica para pacientes con afectación cutánea o para aquellos que precisan altas dosis de corticoesteroides (CE). El objetivo de este estudio es revisar los casos tratados en nuestro servicio y hacer una revisión de la literatura. MATERIAL Y MÉTODOS: Recogida de datos de manera retrospectiva de todos los casos tratados desde marzo de 2011 a octubre de 2014 en el Servicio de Dermatología del Hospital Universitario y Politécnico la Fe de Valencia. RESULTADOS: Recogimos un total de 16 pacientes, 10 tratados con PUVA y 6 con UVB-BE. Nueve pacientes obtuvieron una respuesta completa y 7 una respuesta parcial, aunque 2 recidivaron tras el tratamiento. Diez pacientes pudieron disminuir la dosis de CE durante el tratamiento y 3 pudieron disminuir el número de otros inmunosupresores. No se presentaron efectos adversos graves. CONCLUSIONES: La fototerapia es una buena opción terapéutica para pacientes con EICH crónica con gran afectación cutánea, para aquellos que no responden al tratamiento tópico o para pacientes corticodependientes. Su mayor beneficio es el de ser un tratamiento dirigido a la piel que permite ahorrar CE y que presenta un buen perfil de seguridad. La pauta de tratamiento se realiza de manera individualizada y, según nuestra experiencia, con dosis iniciales y dosis máximas por sesión menores que para otras enfermedades

INTRODUCTION AND OBJECTIVES: Cutaneous chronic graft-vs-host disease (GVHD) is a common complication of hematopoietic stem cell transplantation. Phototherapy is a therapeutic option for patients with skin involvement and for those who require high doses of corticosteroids. We analyze the cases treated in our department and review the literature. MATERIAL AND METHODS: All patients with GVHD treated with phototherapy in the dermatology department of Hospital Universitario y Politécnico la Fe in Valencia, Spain between March 2011 and October 2014 were identified. Data were gathered retrospectively. RESULTS: There were 16 patients: 10 treated with psoralen-UV-A and 6 with narrowband-UV-B. Complete response was achieved in 9 patients and partial response in 7; 2 patients with partial responses relapsed after treatment. Ten patients were able to decrease their dose of corticosteroids during treatment, and a further 3 decreased the number of other immunosuppressant drugs. No serious adverse effects occurred. CONCLUSIONS: Phototherapy is a good therapeutic option for patients with chronic GVHD with extensive cutaneous involvement, as well as for those who fail to respond to topical treatment or who have become steroid-dependent. The main benefits are that, as the treatment targets the skin, it reduces corticosteroid requirements and has a good safety profile. Treatment must be individualized and, in our experience, both the initial dose and the maximum dose per session can be lower than for other diseases

Treatment of localized mycosis fungoides with digital UV photochemotherapy.

BACKGROUND/PURPOSE: Photochemochemotherapy with 8-methoxypsoralen and UV-A light (PUVA) is a well-established treatment for mycosis fungoides (MF), although evidence for this therapy by means of prospective studies is scarce. However, long-term risks of PUVA are premature skin aging and development of nonmelanoma skin cancer. We therefore evaluated a device for targeted UV therapy, which reduces irradiation of unaffected skin in MF patients. METHODS: Ten patients with patch- or plaque-type MF affecting less than 10% body surface area were included in a prospective study. A total of 14 lesions were treated with cream PUVA using the digital phototherapy device skintrek(®) PT3. RESULTS: Seven of ten patients showed response to treatment. Complete clinical remission was achieved in four of ten patients (complete remission of seven of fourteen treated lesions) after an average of 13.4 weeks and an average cumulative UV dose of 42.6 J/cm(2) in a mean of 31.2 treatment sessions. Adverse events were rare and of mild severity. CONCLUSIONS: This study is the first prospective trial demonstrating efficacy and safety of cream PUVA in MF patients. As healthy adjacent skin remains unaffected, the potential to reduce the carcinogenic risk of PUVA treatment makes this new method a promising therapeutic option for localized MF.

Minimal phototoxic dose (MPD) measurements for topical photochemotherapy using a semiautomated MPD tester.

BACKGROUND: The traditional method of assessing minimal phototoxic dose (MPD) prior to photochemotherapy with psoralen-ultraviolet A (PUVA) is inconvenient and cannot directly determine PUVA start doses. A handheld minimal erythema dose UVB tester can be modified by fitting a TL-10 UVA compact fluorescence lamp (CFL). OBJECTIVES: To determine whether MPD testing is possible with a CFL and to calculate a fixed factor to convert observed MPD to PUVA-equivalent MPD. METHODS: Patients had two sets of MPD tests performed on symmetrical, contralateral sites on the lower back. MPD test results from a panel of PUVA lamps were compared with MPD from the modified handheld tester. Additionally, a questionnaire survey was completed by 43 U.K. phototherapy units to assess routine practice concerning MPD testing prior to PUVA therapy. RESULTS: Thirty-seven patients with psoriasis were recruited. Boston phototypes in the 31 with conclusive MPD reactions were: I, four; II, 11; III, 12; and IV, four. The handheld MPD results were linearly related to the PUVA panel MPD results as follows: PUVA MPD = 0·48 × handheld MPD + 0·17 J cm(-2). The measured PUVA MPD was 0·48 of the handheld MPD, not 0·15 as predicted by the published PUVA action spectrum. CONCLUSIONS: The modified MPD tester is a convenient and safe method for PUVA MPD testing, overcoming many problems of the 'traditional method'. The difference between the PUVA and TL-10 lamps was lower than predicted from published studies. This suggests that formal re-evaluation of the erythema action spectrum for PUVA is now needed.

Photo(chemo)therapy for vitiligo.

Vitiligo is a common skin disease characterized by loss of normal melanin pigments in the skin and its pathogenesis is still unclear. Treatment modalities include psoralen plus ultraviolet A, narrow-band ultraviolet B (NB UVB) phototherapy, topical and systemic steroids, topical calcineurin inhibitors, topical vitamin D analogues in monotherapy or in association with phototherapy, and surgical treatment. NB UVB (310-315 nm) radiation is now considered as the 'gold standard' for the treatment of diffuse vitiligo, and treatment with two recently introduced UVB sources that emit 308 nm wavelengths, the 308 nm xenon chloride (XeCl) excimer laser and the 308 nm XeCl excimer light, has also been reported to be effective and might be the treatment of choice for localized disease: this treatment modality has been defined as 'targeted phototherapy.'

Púrpura extensa de largo tiempo de evolución / Long-Standing Widespread Purpura

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Terapia combinada con etanercept y fármacos sistémicos o fototerapia / Combined therapy with etanercept and systemic drugs or phototherapy

La terapia biológica ha mostrado un efecto antipsoriásico muy satisfactorio; sin embargo, dicha respuesta no siempre se alcanza en todos los pacientes y además puede no resultar suficiente para otros. Por ello, recientemente se han diseñado estrategias entre las que destaca el uso de terapias combinadas con fármacos biológicos y sistémicos o la fototerapia. En este trabajo revisamos la terapia combinada con etanercept, fármacos sistémicos y fototerapia, y presentamos un paciente con psoriasis tratado con etanercept y UVB-BE (AU)

Biological therapy has been shown to have a very satisfactory antipsoriasic effect. However, this response is not always achieved in all the patients and may be insufficient for others. Thus, strategies have recently been designed, among which the use of combined therapies with biological and systemic drugs or phototherapy have been designed. In this work, we have reviewed the combined therapy with etanercept, systemic drugs and phototherapy and present the case of a patient with psoriasis treated with etanercept and narrow band UVB (AU)

Recent advances in PUVA photochemotherapy and PDT for the treatment of cancer.

Since ancient times, many cultures worldwide found out independently that the topical administration of some photoactive natural products (mainly extracted from plants) followed by exposure to sunlight, might be an effective treatment of some skin diseases, thus accidently giving birth to the so-called photochemotherapy. In the attempt to resemble nature by exploiting its teaching, during the last two centuries, scientists tried to rationalize this knowledge in order to develop more effective therapeutic strategies and to understand in depth the mechanisms of action involved, expanding the potential application of this therapy to pathologies other than skin diseases, such as some types of tumors. In this paper we aim at giving an overview on results achieved to date on state-of-the-art photochemotherapy related to the treatment of cancer. The script is organized in three sections. Subsequent to a general introduction describing the origin and basic principles of photochemotherapy, the first section deals with the issue concerning the choice of the proper light sources for each type of therapeutic application, stressing the technological advances in the field (e.g. fiber optics). The second and the third sections provide an overview of the two clinically-established phototherapies to date, that is, PUVA photochemotherapy and PDT, respectively. Both sections are further subdivided into sub-paragraphs emphasizing specific relate topics such as principles and applications, employed light sources, and available data concerning anticancer activity. The third section also provides examples of non-conventional metal-based photosensitizers for PDT.

Lesiones ampollosas como forma de presentación de una enfermedad de injerto contra huésped crónica / Chronic graft-versus-host disease presenting as bullous lesions

La enfermedad de injerto contra huésped (EICH) continúa siendo la primera causa de morbilidad y mortalidad en los enfermos con trasplante de médula ósea, de modo que un tratamiento precoz es importante para reducir la gravedad y las consecuencias de esta complicación. Las lesiones cutáneas son en muchas ocasiones la forma de presentación de una EICH y anuncian la afectación visceral. Presentamos el caso de una paciente de 45 años con mieloma múltiple a la que se realizó primero un trasplante autólogo y posteriormente un trasplante alogénico de médula ósea con precursores hematopoyéticos. Desarrolló lesiones ampollosas con eliminación de líquido en el abdomen y los miembros inferiores. Se realizó una biopsia que fue compatible con una EICH y se aumentó el tratamiento inmunodepresor. La paciente posteriormente presentó lesiones liquenoides orales, síndrome seco y las lesiones ampollosas que evolucionaron a úlceras dolorosas, que cicatrizaron con un intenso aspecto esclerodermiforme e importante hiperpigmentación. Las lesiones ampollosas son una forma de presentación excepcional en la EICH crónica, y en estos casos la sospecha inicial del diagnóstico puede ser difícil, sobre todo cuando se presentan de forma aislada sin afectación de órganos internos (AU)

Graft-vs-host disease is still the leading cause of morbidity and mortality in patients undergoing bone marrow transplantation. It is important to start treatment early to reduce the severity and consequences of this complication. Cutaneous lesions are often the presenting compliant of graft-vs-host disease and presage visceral involvement. We present the case of a 45-year-old woman with multiple myeloma who underwent autologous and subsequently allogeneic bone marrow transplantation with hematopoietic precursors. She developed bullous lesions with fluid elimination on the abdomen and legs. Biopsy findings were compatible with graft-vs-host disease and immunosuppressive therapy was increased. She subsequently presented oral lichenoid lesions and sicca syndrome. The bullous lesions progressed to painful ulcers that healed leaving highly sclerodermatous skin with substantial hyperpigmentation. Bullous lesions are a rare form of presentation of chronic graft-vs-host disease. In such cases, the diagnosis may not be suspected initially, particularly when the lesions are isolated and internal organs are not involved (AU)

The contribution of medical physics to the development of psoralen photochemotherapy (PUVA) in the UK: a personal reminiscence.

Psoralen photochemotherapy (PUVA) is the combined treatment of skin disorders with a photosensitizing drug (Psoralen) and UltraViolet A radiation. The introduction of PUVA therapy has arguably been the most important development in dermatology over the past 30 years and from the first days of the treatment being introduced in the UK, British medical physicists were an integral part of the effort to establish it. Medical physicists have contributed to this development in a number of ways, from designing irradiation units in the early days of the technique, through to collaborating with dermatologists in prosecuting clinical and experimental studies aimed at improving patient outcomes. That the dose of UVA radiation is administered quantitatively, and not qualitatively, has probably been the single most important contribution made by several medical physicists over this period. However, despite concerns that were expressed almost 30 years ago about the accuracy with which UVA doses are administered to patients, the medical physics community still has some way to go before we can be satisfied that statements about UVA irradiance and dose can be made with confidence.

Histiocitoma eruptivo generalizado / Generalized eruptive histiocytoma

Presentamos el caso de un varón de 64 años que desarrolló, a lo largo de un periodo de 4 meses, múltiples pápulas asintomáticas distribuidas simétricamente por el tronco y las regiones proximales de las extremidades, respetando cuero cabelludo, palmas, plantas y mucosas. Las lesiones eran discretas, eritematoparduscas, redondeadas, desde ligeramente elevadas a hemisféricas, de 1 a 3 mm de diámetro, y firmes al tacto. Los estudios clínicos, histopatológicos, inmunohistoquímicos y ultraestructurales fueron de histiocitoma eruptivo generalizado. Las pruebas de laboratorio y los estudios radiológicos no mostraron hallazgos anormales. Tras someterse a fotoquimioterapia, las lesiones remitieron, pero más adelante aparecieron nuevos brotes de pápulas. El histiocitoma eruptivo generalizado pertenece a un espectro de enfermedades que pueden solaparse e incluso progresar las unas a las otras. Puesto que la enfermedad podría progresar hacia una dolencia más grave, habría que considerar seriamente revisiones regulares con exámenes clínicos, histológicos e inmunohistoquímicos

We present the case of a 64-year-old male who developed multiple asymptomatic papules over a four-month period, distributed symmetrically on the trunk and proximal regions of the limbs, while the scalp, palms, soles and mucous membranes were spared. The lesions were discrete papules, brownish-erythematous, rounded, ranging from slightly raised to hemispherical, from 1 to 3 mm in diameter and firm to the touch. Clinical, histopathological, immunohistochemical and ultrastructural studies were consistent with generalized eruptive histiocytoma. Laboratory tests and radiological studies did not show any abnormal findings. After being subjected to photochemotherapy, the lesions regressed, but later on new outbreaks of papules appeared. Generalized eruptive histiocytoma belongs to a spectrum of diseases that may overlap; some may even develop into others. As the disease may progress into a more serious ailment, regular checkups with clinical, histological and immunohistochemical examinations should definitely be considered

Comparison of oral psoralen-UV-A with a portable tanning unit at home vs hospital-administered bath psoralen-UV-A in patients with chronic hand eczema: an open-label randomized controlled trial of efficacy.

OBJECTIVE: To study whether oral psoralen-UV-A (PUVA) with a portable tanning unit at home is as effective as hospital-administered bath PUVA in patients with chronic hand eczema. DESIGN: Open-label randomized controlled trial, with a 10-week treatment period and an 8-week follow-up period. SETTING: Two university hospital dermatology departments in the Netherlands, specializing in hand eczema. PATIENTS: One hundred fifty-eight patients with moderate to severe chronic hand eczema (more than 1 year in duration). INTERVENTIONS: Oral PUVA using methoxsalen capsules and a simple portable commercial facial tanning unit, or hospital-administered bath PUVA with trioxsalen. MAIN OUTCOME MEASURES: The primary outcome was clinical assessment by a hand eczema score (evaluation of desquamation, erythema, vesiculation, infiltration, fissures, itch, and pain, each on a 4-point scale) after 10 weeks of treatment. The secondary outcome was hand eczema score at 8 weeks of follow-up, after completion of treatment. The tertiary outcome was travel cost and time off work. RESULTS: Both groups showed a comparable and substantial decrease in hand eczema score (meaningful clinical improvement). This decrease was maintained during the follow-up period. Patients treated with oral PUVA at home had lower travel costs and less time off work. CONCLUSIONS: Oral PUVA at home has a clinically relevant efficacy, similar to that of hospital-administered bath PUVA. This effect was maintained during an 8-week follow-up period. It resulted in lower travel costs and less time off work.

Variation in calibration of hand-held ultraviolet (UV) meters for psoralen plus UVA and narrow-band UVB phototherapy.

BACKGROUND: Phototherapy units should regularly use hand-held ultraviolet (UV) meters to assess the output of treatment lamps, and these meters should be accurately calibrated. Several medical physics departments in the U.K. can calibrate UV meters traceable to national standards, but there is concern that there may be disagreement among departments. In particular, there may be difficulty in calibration for narrow-band UVB phototherapy lamps (TL-01). OBJECTIVES: To ascertain the level of agreement in UV meter calibration at expert centres in the U.K., and to survey methodology at these centres, consider sources of errors and to make recommendations on calibration methods. METHODS: The same UV meter with two detectors (for UVA and UVB) was calibrated by seven medical physics departments. A questionnaire on methods was also distributed and measured spectral outputs from each centre were examined. RESULTS: The calibration factors for the meter varied by +/- 18% for the UVA detector and by +/- 60% for the UVB detector (2 standard deviations). Six centres performed calibration using a spectroradiometer and one centre used a reference meter method. The spectra of lamps used for calibration were similar. For the spectroradiometric methods there were some differences in methodology and instrumentation that may account for the differences in calibration factors. CONCLUSIONS: UV meter calibration in the U.K. shows unacceptable variability, particularly for TL-01 lamps. An accuracy of around of +/- 10% would be clinically acceptable and should be technically achievable.

A device for minimizing the risk of overexposure of patients undergoing phototherapy.

Phototherapy irradiation cabinets normally rely on one timer or dose meter in order to control the ultraviolet (UV) exposure of patients. Faults may occur in the electronic control, or the operator may set the prescribed dose incorrectly. If this happens, a patient will receive an exposure different from that intended, which in the case of overexposure may result in severe burning resulting in hospitalization. Some phototherapy equipment has secondary devices (e.g. mechanical timer) for controlling the dose in case the primary system fails. We have designed and built a secondary dose meter that sounds an alarm if an overdose is about to occur. The unique feature of our device is that it measures the irradiance level within the cabinet and uses this value in combination with the dose set by the operator, to calculate the alarm time. Using the measured irradiance value in this manner ensures that the calculated exposure time compensates for variations in UV output as the lamps age.

The PUVA-turban as a new option of applying a dilute psoralen solution selectively to the scalp of patients with alopecia areata.

BACKGROUND: Alopecia areata is a burden for many patients and often resistant, even to extensive therapy. Orally administered PUVA therapy has been shown among numerous systemic and topical treatment modalities to be a therapeutic alternative. However, the clinical use of oral PUVA is often limited by systemic side effects. Bath-PUVA therapy offers an alternative solution because of the negligible systemic absorption of psoralen with this technique. Through use of a "PUVA-turban" it is now possible to administer a dilute bathwater solution containing 8-methoxypsoralen (8-MOP) to the scalp. OBJECTIVE: The purpose of this study was to determine whether PUVA turban therapy is effective in treating alopecia areata in different clinical stages. METHODS: We treated 9 patients with severe, rapidly progressing, treatment-resistant alopecia areata with PUVA-turban treatment as a modification of bath-PUVA therapy. At each treatment session a cotton towel was soaked with a 0.0001% 8-MOP solution (1 mg/L) at 37 degrees C, wrung gently to remove excess water, and wrapped around the patient's head in a turban fashion for 20 minutes. This was directly followed by UVA radiation. Treatment sessions were initially performed 3 to 4 times per week. RESULTS: The cumulative UVA doses given over treatment periods of up to 24 weeks were 60.9 to 178.2 J/cm(2), with single doses ranging from 0.3 to 8.0 J/cm(2). After up to 10 weeks of treatment, hair regrowth could be noticed in 6 of 9 patients. Two patients did not respond to the treatment, and one patient showed only vellus hair regrowth. CONCLUSION: PUVA-turban therapy can be considered a useful method of administering a dilute psoralen solution selectively to the scalp of patients. It has been shown to be a well-tolerated and, in some patients, efficient therapeutic alternative in the treatment of alopecia areata.

Traceable calibration of ultraviolet meters used with broadband, extended sources.

A calibration system has been developed to provide increased accuracy in the measurement of the irradiance responsivity appropriate for UV meters used with broadband, extended sources of the type employed in phototherapy. The single wavelength responsivity of the test meter is obtained in the wavelength range 250-400 nm by intercomparison with a transfer standard meter in a narrow, monochromatic beam. Traceability to primary standard irradiance scales is provided via the National Measurement System with a best uncertainty of 7% (at 95% confidence). The effective responsivity of the test meter, when used with broadband extended sources, is calculated using the measured spectral and angular response of the meter and tabulated data on the spectral and spatial characteristics of the source radiance. The uncertainty in the effective responsivity, independent of the source variability, is estimated to be 10% (at 95% confidence). The advantages of this calibration system over existing approaches are discussed.

Temperatures reached inside stand-up ultraviolet treatment boxes.

Heat generated within ultraviolet treatment units can exacerbate eczema. To document the actual temperature changes within the treatment units, we measured the air temperatures in standard stand-up psoralen plus ultraviolet A (PUVA), narrowband ultraviolet B (UVB), broadband UVB, and combination UVA/UVB cabinets using a thermocouple thermometer. For the latter unit, we also measured the air temperatures with and without ventilation systems, and actual skin temperatures on individuals undergoing light treatment. The air temperatures rose significantly in all the treatment units, more so with PUVA and narrowband UVB boxes, and were highest with the ventilation systems shut off. Skin temperatures also rose significantly, but less dramatically. Ventilation is essential in maintaining comfortable temperatures within ultraviolet treatment units.