The increased risk of skin cancer is persistent after discontinuation of psoralen+ultraviolet A: a cohort study

Chronic Hand Eczema (CHE): A Narrative Review

Chronic hand eczema (CHE) is a common and challenging skin condition, characterized by persistent hand dermatitis which lasts over 3 months or recurs at least twice a year. This condition is often multifactorial, involving genetic predispositions, environmental factors and triggers, such as irritants and allergens. Studies show a higher incidence in women, though prevalence estimates vary across different age groups. The pathogenesis involves complex immune mechanisms, particularly Th1/Th2 cell responses. Clinically, CHE presents in various forms, with symptoms such as redness, scaling and itching that significantly impact patients' quality of life. Treatment approaches are diverse. While emollients and topical corticosteroids have historically been the mainstay, new systemic therapies like JAK inhibitors and biologics are progressively being used for severe cases. Key molecular targets comprise interleukin (IL)-4 and IL-13, the JAK-STAT pathway, phosphodiesterase 4 (PDE4) and chemoattractant chemokines. Managing CHE effectively remains a challenge because of its chronicity and the variability in individual responses to treatment. However, emerging therapeutic strategies will help clinicians to offer more patient-centred approaches.

Chronic Hand Eczema

Chronic hand eczema (CHE) is a complex, challenging, and frequently multifactorial skin disease of the hands. It is very common in the general population, especially in certain professions. When hand eczema (HE) persists for longer than 3 months or has a minimum of two relapses per year after initial manifestation with complete clearance, it is considered chronic. In this case, health-related quality of life and the patient's working life are often impaired. CHE can be considered as an umbrella term because it covers different clinical pictures and etiologies. To date, there is no definite and unique HE classification. Treatment starts with identifying the individual HE etiology paralleled by symptomatic therapy (local and/or systemic and/or ultraviolet phototherapy). Sustainable management of HE requires the identification and avoidance of its triggering factors, from the professional and private environment. This includes ruling out allergic contact dermatitis if any HE persists for more than 3 months despite adequate therapy. Randomized controlled trials investigating the efficacy in HE are lacking for several treatment modalities. Patient education measures of skin protection and prevention complete the multimodal treatment.

Antiproliferative and Anti-Inflammatory Effects of the Polyphenols Phloretin and Balsacone C in a Coculture of T Cells and Psoriatic Keratinocytes

Plaque psoriasis is a chronic inflammatory skin disease causing red inflamed lesions covered by scales. Leukocytes, including dendritic cells and T cells, participate in the inflammation of the skin by producing multiple cytokines, thus contributing to the hyperproliferation of keratinocytes. Lack of effectiveness and toxic side effects are the main concerns with conventional treatments, and research involving new antipsoriatic molecules is essential. In this study, the anti-inflammatory and antiproliferative effects of two natural polyphenols, phloretin and balsacone C, were investigated using the coculture of T cells and psoriatic keratinocytes. Phloretin exerted antiproliferative activity by regulating the expression of antigen Ki67 and proliferating cell nuclear antigen (PCNA). These effects were comparable to those of methotrexate, a reference treatment for moderate to severe psoriasis. With balsacone C, the expression of Ki67 was also reduced. Additionally, phloretin decreased the levels of multiple pro-inflammatory cytokines: monocyte chemoattractant protein-1 (MCP-1/CCL2), macrophage inflammatory protein-1α (MIP-1α), granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-1 alpha (IL-1α), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), interleukin-17A (IL-17A), and tumor necrosis factor alpha (TNF-α). The increased interleukin-2 (IL-2) levels with phloretin and methotrexate also represented anti-inflammatory activity. Balsacone C and methotrexate decreased the levels of IL-1α and IL-1β, but methotrexate exerted a higher reduction. In summary, the anti-inflammatory effects of phloretin were more pronounced than those of methotrexate and balsacone C. In addition, the expression of lymphocyte common antigen (CD45) was more similar to that of the healthy condition after using phloretin or methotrexate. Finally, phloretin stood out from the other compounds and appears promising for psoriasis treatment.

Effect of P. corylifolia on the pharmacokinetic profile of tofacitinib and the underlying mechanism

This work aimed to explore the mechanisms underlying the interaction of the active furanocoumarins in P. corylifolia on tofacitinib both in vivo and in vitro. The concentration of tofacitinib and its metabolite M8 was determined using UPLC-MS/MS. The peak area ratio of M8 to tofacitinib was calculated to compare the inhibitory ability of furanocoumarin contained in the traditional Chinese medicine P. corylifolia in rat liver microsomes (RLMs), human liver microsomes (HLMs) and recombinant human CYP3A4 (rCYP3A4). We found that bergapten and isopsoralen exhibited more significant inhibitory activity in RLMs than other furanocoumarins. Bergapten and isopsoralen were selected to investigate tofacitinib drug interactions in vitro and in vivo. Thirty rats were randomly allocated into 5 groups (n = 6): control (0.5% CMC-Na), low-dose bergapten (20 mg/kg), high-dose bergapten (50 mg/kg), low-dose isopsoralen (20 mg/kg) and ketoconazole. 10 mg/kg of tofacitinib was orally intervented to each rat and the concentration level of tofacitinib in the rats were determined by UPLC-MS/MS. More imporrantly, the results showed that bergapten and isopsoralen significantly inhibited the metabolism of tofacitinib metabolism. The AUC(0-t), AUC(0-∞), MRT(0-t), MRT(0-∞) and Cmax of tofacitinib increased in varying degrees compared with the control group (all p < 0.05), but CLz/F decreased in varying degrees (p < 0.05) in the different dose bergapten group and isopsoralen group. Bergapten, isopsoralen and tofacitinib exhibit similar binding capacities with CYP3A4 by AutoDock 4.2 software, confirming that they compete for tofacitinib metabolism. P. corylifolia may considerably impact the metabolism of tofacitinib, which can provide essential information for the accurate therapeutic application of tofacitinib.

S2k-Leitlinie Diagnostik, Prävention und Therapie des Handekzems: S2k guideline diagnosis, prevention and therapy of hand eczema

Die S2k‐Leitlinie „Diagnostik, Prävention und Therapie des Handekzems (HE)“ gibt auf der Grundlage eines evidenz‐ und konsensbasierten Ansatzes konkrete Handlungsanweisungen und Empfehlungen für die Diagnostik, Prävention und Therapie des HE. Die Leitlinie wurde auf der Grundlage der deutschen Leitlinie „Management von Handekzemen“ aus dem Jahr 2009 und der aktuellen Leitlinie der European Society of Contact Dermatitis (ESCD) „Guidelines for diagnosis, prevention and treatment of hand eczema“ aus dem Jahr 2022 erstellt. Allgemeines Ziel der Leitlinie ist es, Dermatologen und Allergologen in der Praxis und Klinik eine akzeptierte, evidenzbasierte Entscheidungshilfe für die Auswahl sowie Durchführung einer geeigneten und suffizienten Therapie für Patienten mit Handekzemen zur Verfügung zu stellen. Die Leitlinie basiert auf zwei Cochrane‐Reviews zu therapeutischen und präventiven Interventionen beim HE. Die übrigen Kapitel wurden überwiegend basierend auf nicht systematischen Literaturrecherchen durch die Expertengruppe erarbeitet und konsentiert. Die Expertenkommission bestand aus Mitgliedern von allergologischen und berufsdermatologischen Fachgesellschaften und Arbeitsgruppen, einer Patientenvertretung und Methodikern. Im Rahmen einer Konsensuskonferenz am 15.09.2022 wurden die Vorschläge für die Empfehlungen und Kernaussagen unter Verwendung eines nominalen Gruppenprozesses konsentiert. Der strukturierte Konsensfindungsprozess wurde professionell moderiert. Die vorliegende Leitlinie hat eine Gültigkeit bis zum 22.02.2028.

S2k guideline diagnosis, prevention, and therapy of hand eczema

The consensus-based guideline "Diagnosis, prevention, and treatment of hand eczema (HE)" provides concrete instructions and recommendations for diagnosis, prevention, and therapy of HE based on an evidence- and consensus-based approach. The guideline was created based on the German guideline "Management von Handekzemen" from 2009 and the current guideline of the European Society of Contact Dermatitis (ESCD) "Guidelines for diagnosis, prevention, and treatment of hand eczema" from 2022. The general goal of the guideline is to provide dermatologists and allergologists in practice and clinics with an accepted, evidence-based decision-making tool for selecting and conducting suitable and sufficient therapy for patients with hand eczema. The guideline is based on two Cochrane reviews of therapeutic and preventive interventions for HE. The remaining chapters were mainly developed and consented based on non-systematic literature research by the expert group. The expert group consisted of members of allergological and occupational dermatological professional associations and working groups, a patient representative, and methodologists. The proposals for recommendations and key statements were consented by using a nominal group process during a consensus conference on September 15, 2022. The structured consensus-building process was professionally moderated. This guideline is valid until February 22, 2028.

Incidence of skin malignancies in patients with vitiligo or psoriasis who received narrowband ultraviolet B phototherapy (308 nm/311 nm): A retrospective review of 3730 patients

BACKGROUND

Previous studies regarding the risk of skin malignancy with NBUVB have been performed in Caucasian patients, but few studies have been conducted in Asians.

AIM

The aim of the study was to determine the risk of skin cancer in Asian patients with psoriasis and vitiligo receiving NBUVB phototherapy.

METHODS

We performed a 9-year retrospective study including all patients with psoriasis and vitiligo receiving NBUVB (either 311 nm wavelength through cabin phototherapy or 308 nm through excimer lamp phototherapy) at the National Skin Centre. We matched the identification numbers of patients to the National Registry of Diseases Office database and collected data on all skin cancers diagnosed.

RESULTS

A total of 3730 patients were included. During the course of the study, 12 cases of skin cancer were diagnosed, of which 10 were basal cell carcinomas, and 2 were squamous cell carcinomas. No cases of melanoma were detected in the study. The age-standardized incidence of skin cancer in psoriasis and vitiligo patients who received phototherapy was 47.5 and 26.5, respectively, which is higher than the incidence of skin cancers in the general population. Risk of skin malignancy was positively correlated with the cumulative (p = .008) and maximum dose of phototherapy (p = .011) as well as previous systemic treatments (p = .006).

LIMITATIONS

Limitations include a relatively short follow-up period as well as the lack of quantification of solar exposure.

CONCLUSIONS

NBUVB phototherapy in Asian skin increases the risk of skin malignancy. The risk of skin malignancy is higher with psoriasis patients, greater cumulative and maximal dose of phototherapy as well as the use of systemic therapy. Despite the increased risk, the absolute number of skin malignancies remains low, especially for vitiligo patients, with no cases of melanoma diagnosed-a reassuring finding that phototherapy remains a safe alternative in the treatment of psoriasis and vitiligo.

Blue light-emitting diodes for the treatment of localized vitiligo: A retrospective study

BACKGROUND

Vitiligo is an autoimmune dermatological disease characterized by hypopigmented macules. Treatments include topical agents, phototherapy, and laser therapies. Different lasers should be individually chosen regarding location, extent, activity of the disease.

AIMS

This article aims to demonstrate how blue LED is effective and safe, as its wavelength is very close to the UV spectrum (415 nm vs. 400 nm), but, unlike UV therapy, blue LED have not shown any long-term cancerogenic side effects.

PATIENTS/METHODS

We treated 30 patients affected by vitiligo localized on different anatomical areas with blue light-emitting diodes.

RESULTS

Complete repigmentation occurred in 75.33% of treated patients (22 out of 30 patients, 14 males, and 8 females). Partial repigmentation occurred in the remaining patients.

CONCLUSIONS

Blue LED light may be a safe and well-tolerated way to induce repigmentation in patients affected by vitiligo.

Ultraviolet Radiation and Basal Cell Carcinoma: An Environmental Perspective

Ultraviolet radiation (UVR) is a known carcinogen participated for the development of skin cancers. Solar UVR exposure, particularly ultraviolet B (UVB), is the mostly significant environmental risk factor for the occurrence and progress of basal cell carcinoma(BCC). Both cumulative and intermittent high-grade UVR exposure could promote the uncontrolled replication of skin cells. There are also exsiting other contributing environmental factors that combine with the UVR exposure to promote the development of BCC. DNA damage in formation of skin cancers is considered to be a result of UVR toxicity. It is UVR that could activate a series of oncogenes simultaneously inactivating tumor suppressor genes and aberrant proliferation and survival of keratinocytes that repair these damages. Furthermore, mounting evidence demonstrates that inflammatory responses of immune cells in the tumor microenvironment plays crucial role in the skin tumorigenesis as well. In this chapter, we will follow the function of UVR in the onset and development of BCC. We describe the factors that influence BCC induced by UVR, and also review the recent advances of pathogenesis of BCC induced by UVR from the genetic and inflammatory aspects.

Citrus Consumption and the Risk of Non-Melanoma Skin Cancer in the Women's Health Initiative

Simple Summary

Citrus products are rich in furocoumarins, which can increase the risk of incident non-melanoma skin cancer (NMSC) when combined with ultraviolet radiation. However, few observational studies have evaluated the link between citrus intake and NMSC incidence. The aim of this study was to determine whether citrus intake was related to the NMSC incidence in participants of the Women’s Health Initiative Observational Study. The results of this study indicated that high citrus juice consumption was associated with a higher risk of incident NMSC compared to low consumption. These findings add further evidence of the potentially carcinogenic nature of certain citrus products and highlight the need to continue investigations in identifying risk factors and mechanisms.

Abstract

Evidence from animal studies suggests that furocoumarins, compounds present in citrus products, can increase the risk of non-melanoma skin cancer (NMSC) when combined with ultraviolet radiation. The objective of this study was to determine the relationship between citrus intake and NMSC risk among postmenopausal women from the Women’s Health Initiative (WHI) Observational Study, who were aged 50–79 years at enrollment (1993–1998). The consumption of citrus fruit, citrus juice, and non-citrus fruit and juice were measured at the baseline of the study using a food frequency questionnaire (FFQ). NMSC cases (basal or squamous cell carcinomas) were self-reported during annual follow-up surveys. The outcome data used for this analysis were collected through March 2020. The relative risk (RR) for incident NMSC by citrus consumption was calculated. Among 49,007 non-Hispanic white participants, there were 8642 cases of incident NMSC. Using less than one serving of citrus juice per week as reference, the RRs and 95% confidence intervals (CI) for incident NMSC by citrus juice intake were 1.03 (0.95, 1.10) for one serving/week, 1.06 (1.00, 1.12) for two to four servings/week, 0.98 (0.90, 1.07) for five to six servings/week, and 1.08 (1.02, 1.13) for one or more serving/day (p-trend = 0.007). Subgroup analyses did not reveal meaningful associations by sun exposure variables. In conclusion, there were indications of a slightly higher risk of incident NMSC among citrus juice consumers; however, further longitudinal and mechanistic studies are needed to confirm the key risk factors.

Does UV Light as an Adjunct to Conventional Treatment Improve Healing and Reduce Infection in Wounds? A Systematic Review

OBJECTIVE

To examine the effect of UV light on wound healing and infection in patients with skin ulcers or surgical incisions. Outcomes of interest included healing time, wound size and appearance, bacterial burden, and infection.

DATA SOURCES

Ovid MEDLINE, Embase, Cochrane, PubMed, CINAHL, and Web of Science.

STUDY SELECTION

Comparative and noncomparative clinical studies were considered, including observational cohort, retrospective, and randomized controlled studies. They addressed the research question: "Does the use of UV light as an adjunct to conventional treatment help improve healing and reduce infection in wounds?" Selection criteria included any English language study in adults who used UV light to improve wound healing and prevent or treat wound infection.

DATA EXTRACTION

Authors extracted information pertaining to patient demographics, treatment protocols, and the following wound outcomes: appearance, healing time, infection, and bacterial burden.

DATA SYNTHESIS

The search yielded 30,986 articles, and screening resulted in 11 studies that underwent final analysis. Of these (N = 27,833), seven (64%) demonstrated an improvement in healing outcomes with adjunctive UV therapy, and the results of four (36%) achieved statistical significance.

CONCLUSIONS

There is limited research on the utility of adjunctive UV therapy to improve wound healing outcomes in humans. The majority of literature included in this review supported improved wound healing outcomes with adjuvant UV therapy. Future well-designed randomized controlled trials will be essential in further determining the benefit and utility of UV therapy in wound healing.

Evaluation for Skin Cancer and Precancer in Patients With Vitiligo Treated With Long-term Narrowband UV-B Phototherapy

Importance

Narrowband UV-B (NBUVB) phototherapy has been the mainstay in the treatment of vitiligo, but its long-term safety in terms of photocarcinogenesis has not been established.

Objectives

To investigate the risks of skin cancer and precancerous lesions among patients with vitiligo undergoing NBUVB phototherapy, based on the number of NBUVB phototherapy sessions.

Design, Setting, and Participants

This nationwide population-based retrospective cohort study enrolled 60 321 patients with vitiligo 20 years or older between January 1, 2007, and December 31, 2017. Patients and outcomes were identified through nationwide cohort data from the Korean national health insurance claims database, and frequency matching by age and sex was performed.

Exposures

The number of phototherapy sessions each patient received between 2008 and 2017. Patients were classified into 5 groups according to the number of phototherapy sessions (0 sessions, 20 105 patients; 1-49 sessions, 20 106 patients; 50-99 sessions, 9702 patients; 100-199 sessions, 6226 patients; and ≥200 sessions, 4182 patients). We also identifed patients who underwent at least 500 phototherapy sessions (717 patients).

Main Outcomes and Measures

Primary outcomes were the development of actinic keratosis, Bowen disease, nonmelanoma skin cancer, or melanoma after enrollment.

Results

Among the 60 321 patients with vitiligo in this study (33 617 women; mean [SD] age, 50.2 [14.9] years), the risks of Bowen disease (<50 sessions of phototherapy: hazard ratio [HR], 0.289 [95% CI, 0.060-1.392]; 50-99 sessions: HR, 0.603 [95% CI, 0.125-2.904]; 100-199 sessions: HR, 1.273 [95% CI, 0.329-4.924]; ≥200 sessions: HR, 1.021 [95% CI, 0.212-4.919]), nonmelanoma skin cancer (<50 sessions: HR, 0.914 [95% CI, 0.533-1.567]; 50-99 sessions: HR, 0.765 [95% CI, 0.372-1.576]; 100-199 sessions: HR, 0.960 [95% CI, 0.453-2.034]; ≥200 sessions: HR, 0.905 [95% CI, 0.395-2.073]), and melanoma (<50 sessions: HR, 0.660 [95% CI, 0.286-1.526]; 50-99 sessions: HR, 0.907 [95% CI, 0.348-2.362]; 100-199 sessions: HR, 0.648 [95% CI, 0.186-2.255]; ≥200 sessions: HR, 0.539 [95% CI, 0.122-2.374]) did not increase after phototherapy. The risk of actinic keratosis increased significantly for those who had undergone 200 or more NBUVB phototherapy sessions (HR, 2.269 [95% CI, 1.530-3.365]). A total of 717 patients with vitiligo underwent at least 500 sessions of NBUVB phototherapy; their risks of nonmelanoma skin cancer and melanoma were no greater than those of the patients who did not undergo NBUVB phototherapy (nonmelanoma skin cancer: HR, 0.563 [95% CI, 0.076-4.142]; melanoma: HR, not applicable).

Conclusions and Relevance

Our results suggest that long-term NBUVB phototherapy is not associated with an increased risk of skin cancer in patients with vitiligo and that NBUVB phototherapy may be considered a safe treatment.

Evidence for a non-stochastic two-field hypothesis for persistent skin cancer risk

With recurring carcinogen exposures, individual tumors develop in a field of genetic mutations through a stepwise process of clonal expansion and evolution. Once established, this “cancer field” persists in the absence of continued carcinogen exposures, resulting in a sustained risk for cancer development. Using a bioimaging approach, we previously demonstrated that a dermal premalignant field characterized by inflammatory angiogenesis persists following the cessation of ultraviolet light exposures and accurately predicts future overlying epidermal tumor formation. Following ultraviolet light treatments, others have observed that patches of p53 immunopositive cells persist stochastically throughout the epidermal stem cell population. However, these studies were done by random biopsies, introducing sampling bias. We now show that, rather than being randomly distributed, p53⁺ epidermal cells are enriched only in areas overlying this multi-focal dermal field. Moreover, we also show that the dermal field is characterized by a senescent phenotype. We propose that persistence of the overlying epithelial cancerization field in the absence of exogenous carcinogens or promoters requires a two-field composite consisting of a dermal senescent field driving the persistence of the overlying epidermal cancer field. These observations challenge current models that suggest that persistence of cancer risk in the absence of continued carcinogen exposures is simply a function of stochastically arranged, long-lived but dormant epithelial clonal stem cells mutants. The model proposed here could provide new insights into how cancer risk persists following cessation of carcinogenic exposures.

Periocular Basal Cell Carcinoma: 20-Years Experience at a Tertiary Eye Care Center of South India

PURPOSE

To study the clinical profile and management outcomes of periocular basal cell carcinoma (BCC).

MATERIALS AND METHODS

A retrospective analysis of all histopathologically proven cases of BCC between 1995 and 2015 was done. The demographic data, clinical presentation, histopathological subtype, and management outcomes were analyzed.

RESULTS

We had a total of 185 malignant eyelid tumors during the study period, out of which 37 (20%) were BCC. Thirty-two (86.5%) out of 37 cases were primary BCC. The mean age was 63.3 years. Pigmented ulcerative lesion (14, 38%), lower eyelid (19, 51%), and nodular BCC (15, 40%) were the most common presentation, periocular site, and histological subtype, respectively. 28 patients underwent excision under frozen section with an average tumor-free margin of 3.5 mm. Mean follow-up period was 18.78 months. Recurrence rate of 0% and 3.1% was noted in primary and recurrent BCC, respectively.

CONCLUSION

Periocular BCC commonly presents as pigmented ulcerative lesion in the lower lid. Excision biopsy under frozen section with an average tumor-free margin of 3.5 mm offers cure in most cases.

Effects of Psoralen on Histone-DNA Interactions Studied by Using Atomic Force Microscopy

The investigation of the DNA-histone interactions and factors that affect such interactions in the nucleosome is essential for understanding the role of chromatin organization in all cellular processes involved in the repair, transcription, and replication of the eukaryotic genome. As a kind of photosensitive molecule, psoralen (PSO) is used in the treatment of skin disease with ultraviolet light (PSO and ultra violet light, type A). The effect of treatment is remarkable, but the side effect is also obvious. PSO can be embedded in a 5' TA sequence in double-stranded DNA (dsDNA), and dsDNA is mainly wrapped around a histone octamer to form a nucleosome structure in human cells. Therefore, it is very necessary to explore the influence of PSO on DNA-histone interactions. To this end, the binding specificity and mode of DNA and histone in the presence or absence of PSO are investigated systematically. The results show that the presence of PSO (no matter if there is ultra violet light treatment) can increase the overall probability of histone binding to dsDNA while lowering the selectivity of histone binding to the specific DNA sequence in vitro. In addition, the increase of solution ionic strength can lower the ratio of histone binding to nonspecific DNA.

Phototherapy for Cutaneous T-Cell Lymphoma

Phototherapy with psoralen and ultraviolet A (PUVA) or narrowband-UVB (NBUVB) is frequently used for the patch and plaque stages of mycosis fungoides (MF), the most common type of cutaneous T-cell lymphoma. This article provides practical guidelines for the design and implementation of a phototherapy protocol for early stage MF, including an overview of treatment phases, response criteria, and considerations in the selection of a light source. Several evolving topics in phototherapy research are also discussed, including the relative efficacy of PUVA versus NBUVB, the role of maintenance therapy, risk of photocarcinogenicity, and combination therapies.

Furanocoumarins in anticancer therapy - For and against

Furanocoumarins are a class of natural compounds produced by several plants, including those consumed by humans. They have been used medicinally in eastern countries for ages. Given the growing body of evidence about their anticancer potential and observations that naturally occurring compounds potentiate the antitumor activity of chemotherapeutics, more attention is paid to elucidation of the nature of furanocoumarins and the possibility of using thereof in practice. The general mechanism by which furanocoumarins eliminate cancer cells is based on cell cycle blockage and initiation of programmed death like apoptosis or autophagy. The precise molecular mechanism of such an action depends on the chemical structure of furanocoumarins, which is based on the furan ring attached to the coumarin backbone in a linear or angular form as well as the type, location, and number of the substituents attached. The review summarizes the current evidence of the antitumor properties of linear and angular furanocoumarins with special emphasis on the molecular mechanism of elimination of cancer cells via apoptosis and autophagy. Negative aspects of the use of coumarins in anticancer therapy will be also discussed especially in the context of their phototoxicity and potential cancerogenic effect.

Effectiveness of paint psoralen and ultraviolet-A in alopecia areata – Our experience in the national skin center

Background:

Alopecia areata (AA) is usually a benign cause of patchy hair loss that often resolves within a few weeks to months. Most treatment modalities are ineffective in the treatment of severe AA. The use of paint psoralen and ultraviolet-A (PUVA) in the treatment of patients with severe forms of AA has been reported in the literature.

Aims and Objective:

The aim of this study was to evaluate the effectiveness of paint PUVA therapy in the treatment of AA in Singapore.

Materials and Methods:

We performed a 10-year retrospective analysis of patients who underwent paint PUVA for AA. We evaluated patient demographics and treatment outcomes in the form of percentage change in baseline severity of alopecia tool score and final amount of hair regrowth and relapse rate.

Results:

Ten patients were included in this study. With paint PUVA therapy, significant hair regrowth was seen in six patients. Paint PUVA therapy in our study showed minimal side effects.

Conclusion:

PUVA gives fair response in AA in a reasonable time as per our center's experience in Singapore.

The frequency of photosensitizing drug dispensings in Austria and Germany: a correlation with their photosensitizing potential based on published literature

Background

Drug‐induced photosensitivity refers to the development of cutaneous adverse events due to interaction between a pharmaceutical compound and sunlight. Although photosensitivity is a very commonly listed side‐effect of systemic drugs, reliable data on its actual incidence are lacking so far.

Objectives

A possible approach to evaluate the real‐life extent of drug‐induced photosensitivity would be an analysis of the frequency of exposure to a given photosensitizing drug combined with an indicator of its photosensitizing potential. This could serve as a basis for developing a pharmaceutical ‘heatmap’ of photosensitivity.

Methods

The present study investigated the number of reimbursed dispensed packages of potentially photosensitizing drugs in Germany (DE) and Austria (AT) between 2010 and 2017 based on nationwide health insurance‐based databases. In addition, an indicator for the photosensitizing potential was established for each drug based on the number of reports on photosensitivity in the literature.

Results

This analysis includes means of 632 826 944 (+/−14 894 918) drug dispensings per year in DE and 113 270 754 (+/−1 964 690) in AT. Out of these, the mean percentage of drugs that enlist photosensitivity as a potential side‐effect was 49.5% (±0.7) in DE and 48.2% (±1.2) in AT. When plotting the number of reimbursed dispensed packages vs. the number of reports on photosensitivity, two categories of drugs show high numbers for both parameters, that is diuretics and non‐steroidal anti‐inflammatory drugs (NSAIDs).

Conclusions

Diuretics and NSAIDs appear to be responsible for the greatest part of exposure to photosensitizing drugs with potential implication on public health.

A cross-sectional analysis of skin cancer risk in patients receiving narrow-band ultraviolet B phototherapy: an evaluation of 100 patients

Narrow-band ultraviolet B (NB-UVB) phototherapy is an effective and widely used treatment modality for psoriasis and other inflammatory skin diseases. The carcinogenic effect of PUVA treatment has been investigated extensively, but there is very scarce data about the role of NB-UVB in the development of skin cancer. The aim of this study was to investigate the potential carcinogenic risk of NB-UVB therapy in various skin disorders. In this cross-sectional study, we evaluated 100 patients who had received whole-body NB-UVB treatment and 100 age- and sex-matched controls. Phototherapy unit database was used to identify patients. A total of 100 patients (53 males and 47 females) treated with NB-UVB and 100 controls were included in the study. The patient group revealed no cases of melanoma or non-melanoma skin cancer, while ten of them were found to have solar lentigines. Basal cell carcinoma in a patient and nine patients with solar lentigines were detected in the control group. There was no statistically significant difference between patient and control groups in terms of skin cancer and solar lentigines. This study does not provide evidence for an increased skin cancer risk in patients treated with NB-UVB phototherapy. However, we have detected the occurence of 10 cases of solar lentigines. Still, definitive prospective longitudinal studies with a greater number of patients and prolonged follow-up are required to specifically address skin cancer risk in relation to NB-UVB phototherapy.

Distinguishing Myth from Fact: Photocarcinogenesis and Phototherapy

Ultraviolet (UV) radiation contributes to the development of skin cancer through direct and indirect DNA damage, production of reactive oxygen species, and local immunomodulation. The association between UV radiation and skin cancer has raised concern for the risk of carcinogenesis following phototherapy. The photocarcinogenic impact of psoralen and UVA radiation (PUVA) has been extensively studied, whereas limited safety studies exist for other phototherapy modalities, such as broadband and narrowband UVB and UVA1. Because of the as of yet unclear risk, patients who have undergone any type of phototherapy should be followed for age-appropriate skin cancer screening.

Drug and chemical induced photosensitivity from a clinical perspective

Drug photosensitivity is a relatively common occurrence and a range of mechanisms may be involved. Some of these mechanisms will be discussed, including the most common, that of drug phototoxicity. Different types of photosensitivity are addressed with respect to clinical presentation, mechanisms and additionally the contribution to our understanding through clinically directed investigations and regulatory requirements. Repeated controlled therapeutic use of drug phototoxicity, with psoralen-UVA (PUVA) photochemotherapy and photodynamic therapy (PDT) will also be discussed. Finally, the potential for drug-induced photocarcinogenesis will also be covered.

Comparative effectiveness of treatment of actinic keratosis with topical fluorouracil and imiquimod in the prevention of keratinocyte carcinoma: A cohort study

BACKGROUND

The effectiveness of 5-fluorouracil compared with that of imiquimod for preventing keratinocyte carcinoma is unknown.

OBJECTIVE

To compare the effectiveness of 5-fluorouracil and that of imiquimod in preventing keratinocyte carcinoma in a real-world practice setting.

METHODS

We identified 5700 subjects who filled prescriptions for 5-fluorouracil or imiquimod for treatment of actinic keratosis in 2007. An intention-to-treat analysis controlling for potential confounding variables was used to calculate 2- and 5-year cumulative risk differences for subsequent keratinocyte carcinoma overall and in field-treated areas.

RESULTS

5-Fluorouracil was associated with a statistically significant decreased risk of any keratinocyte carcinoma compared with imiquimod (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.76-0.97), but there were no significant differences in risk by tumor subtype (for squamous cell carcinoma: aHR, 0.89; 95% CI, 0.74-1.07; for basal cell carcinoma: aHR, 0.87; 95% CI, 0.74-1.03) or site-specific keratinocyte carcinoma (aHR, 0.96; 95% CI, 0.81-1.14). There were no significant differences in 2- or 5-year cumulative risk of keratinocyte carcinoma among those treated with 5-fluorouracil versus with imiquimod.

LIMITATIONS

Generalizability to other practice settings may be limited.

CONCLUSIONS

Whereas 5-fluorouracil was more effective in reducing keratinocyte carcinoma risk overall, we found no differences in the short- or long-term risk of subsequent site-specific keratinocyte carcinoma in a real-world practice setting.

Comparative effectiveness of treatment of actinic keratosis with topical fluorouracil and imiquimod in the prevention of keratinocyte carcinoma: A cohort study

BACKGROUND

The effectiveness of 5-fluorouracil compared with that of imiquimod for preventing keratinocyte carcinoma is unknown.

OBJECTIVE

To compare the effectiveness of 5-fluorouracil and that of imiquimod in preventing keratinocyte carcinoma in a real-world practice setting.

METHODS

We identified 5700 subjects who filled prescriptions for 5-fluorouracil or imiquimod for treatment of actinic keratosis in 2007. An intention-to-treat analysis controlling for potential confounding variables was used to calculate 2- and 5-year cumulative risk differences for subsequent keratinocyte carcinoma overall and in field-treated areas.

RESULTS

5-Fluorouracil was associated with a statistically significant decreased risk of any keratinocyte carcinoma compared with imiquimod (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.76-0.97), but there were no significant differences in risk by tumor subtype (for squamous cell carcinoma: aHR, 0.89; 95% CI, 0.74-1.07; for basal cell carcinoma: aHR, 0.87; 95% CI, 0.74-1.03) or site-specific keratinocyte carcinoma (aHR, 0.96; 95% CI, 0.81-1.14). There were no significant differences in 2- or 5-year cumulative risk of keratinocyte carcinoma among those treated with 5-fluorouracil versus with imiquimod.

LIMITATIONS

Generalizability to other practice settings may be limited.

CONCLUSIONS

Whereas 5-fluorouracil was more effective in reducing keratinocyte carcinoma risk overall, we found no differences in the short- or long-term risk of subsequent site-specific keratinocyte carcinoma in a real-world practice setting.

Cancer risk in 892 089 patients with psoriasis in Korea: A nationwide population-based cohort study

The relationship between psoriasis and cancer has not yet been established. The aim of this study was to evaluate the association of psoriasis with certain cancers using national statistics. All patients with psoriasis (n = 892 089; 51.7% male) and age- and sex-matched control subjects (n = 4 460 445) at a 5:1 ratio were enrolled using data from the National Health Insurance Service between 2007 and 2014 in Korea. In psoriatic subjects, overall cancer risk was higher than for subjects without psoriasis after adjusting for income level, diabetes, hypertension, dyslipidemia and place of residence (hazard ratio, 1.065; 95% CI, 1.049-1.081). The risk of cancer increased in the following order: prostate, thyroid, liver, ovarian, lung, leukemia, skin, multiple myeloma, lymphoma and testicular. The severity and sex of psoriatic patients also had different cancer risks. In psoriatic patients, a slightly increased risk for specific malignant neoplasms was shown. Therefore, periodic screening for cancer risk is recommended in patients with psoriasis.

Photochemical and Photodynamical Properties of Sulfur-Substituted Nucleic Acid Bases

Sulfur-substituted nucleobases (a.k.a., thiobases) are among the world's leading prescriptions for chemotherapy and immunosuppression. Long-term treatment with azathioprine, 6-mercaptopurine and 6-thioguanine has been correlated with the photoinduced formation of carcinomas. Establishing an in-depth understanding of the photochemical properties of these prodrugs may provide a route to overcoming these carcinogenic side effects, or, alternatively, a basis for developing effective compounds for targeted phototherapy. In this review, a broad examination is undertaken, surveying the basic photochemical properties and excited-state dynamics of sulfur-substituted analogs of the canonical DNA and RNA nucleobases. A molecular-level understanding of how sulfur substitution so remarkably perturbs the photochemical properties of the nucleobases is presented by combining experimental results with quantum-chemical calculations. Structure-property relationships demonstrate the impact of site-specific sulfur substitution on the photochemical properties, particularly on the population of the reactive triplet state. The value of fundamental photochemical investigations for driving the development of ultraviolet-A chemotherapeutics is showcased. The most promising photodynamic agents identified thus far have been investigated in various carcinoma cell lines and shown to decrease cell proliferation upon exposure to ultraviolet-A radiation. Overarching principles have been elucidated for the impact that sulfur substitution of the carbonyl oxygen has on the photochemical properties of the nucleobases.

Management of actinic keratosis at specific body sites in patients at high risk of carcinoma lesions: expert consensus from the AKTeam™ of expert clinicians

Actinic keratoses (AK) arise on sun-exposed regions of the skin. If left untreated, AK may progress to invasive squamous cell carcinoma (SCC), although the rate of progression is low. A practical treatment algorithm for the treatment of AK in standard situations has been published by the AKTeam^™ expert panel. However, management of particular situations of AK with increasing/higher carcinoma risk or AK progressing into carcinomas with increased aggressiveness due to their anatomical location (risky areas), or in patients with an increased risk of SCC requires further discussion. These include AK on the dorsal hands, forearms, legs, periorbital region, eyelids, ears, or lips, and organ transplant recipients, patients undergoing treatment with carcinogenic agents and patients with chronic lymphocytic leukaemia. The main objective was to propose therapeutic strategies for the treatment of AK located in risky areas and in patients with more invasive/aggressive lesions and a higher risk of progression to SCC. A systematic review of the literature was initially performed, and results were discussed by the experts to propose best management practices in specific situations. Finally, adapted management strategies for AK occurring in risky areas and in high-risk patients are presented, taking into account the experts' own clinical experience and current guidelines. In most of these 'at-risk' situations, patients can be treated according to the AKTeam^™ treatment algorithm. Difficult-to-treat lesions should be treated more aggressively due to their higher risk of transformation. For patients with skin that is highly susceptible to actinic damage, monitoring and sun protection strategies are mandatory, and patients should undergo more regular follow-up. Further assessment of newer therapies in clinical trials is necessary to determine optimal treatment conditions. This expert consensus provides guidance for the management of AK in risky body sites and in patients with an increasing/higher risk for SCCs.

A real-world, community-based cohort study comparing the effectiveness of topical fluorouracil versus topical imiquimod for the treatment of actinic keratosis

BACKGROUND

The most widely used topical agents for the field-based treatment of multiple actinic keratoses (AKs) are 5-fluorouracil and imiquimod, but their comparative effectiveness has not been assessed in a real-world setting.

OBJECTIVE

We compared the effectiveness of 5-fluorouracil and imiquimod in reducing risk for subsequent AKs in a large, integrated health care delivery system in northern California.

METHODS

In this cohort study, we identified adult health plan members who had an AK diagnosed in 2007 and who subsequently filled a prescription for 5-fluorouracil or imiquimod (N = 5700). We followed subjects for subsequent AKs identified by the International Classification of Diseases codes and estimated the 2-year (short-term) and 5-year (long-term) differences in cumulative risk while controlling for potential confounding by pretreatment variables.

RESULTS

5-Fluorouracil reduced the short-term incidence of subsequent AKs (cumulative risk difference -4.54% [95% confidence interval, -7.91% to -1.17%]), but there was no statistically significant evidence of a long-term decreased risk (cumulative risk difference -1.43% [95% confidence interval, -3.43% to 0.05%]) compared with that with imiquimod.

LIMITATIONS

This is a retrospective study with limited ascertainment of all relevant potential confounding variables.

CONCLUSION

We found that 5-fluorouracil appeared to be significantly more effective than imiquimod in the short-term, but not long-term, prevention of subsequent AKs.

Identification and Quantitation of Furocoumarins in Popularly Consumed Foods in the U.S. Using QuEChERS Extraction Coupled with UPLC-MS/MS Analysis

Furocoumarins are a class of photoactive compounds found in several plant species and may be responsible for the observed association between consumption of citrus products and the risk of skin cancer. Furocoumarin contents of several foods have been reported previously, but no comprehensive database of furocoumarin content of foods is currently available. Therefore, this study aimed to determine the distribution of furocoumarins in popularly consumed foods in the U.S. Samples of three varieties of each of 29 foods known or suspected to contain furocoumarins were purchased, prepared for analysis using a solid phase extraction method, and analyzed using UPLC-MS/MS for the presence of seven major furocoumarins. Most foods measured contained more than one furocoumarin, and some contained all seven of the furocoumarins examined. Total furocoumarin concentration was greatest in fresh parsley (23215 ng/g), grapefruits (21858 ng/g), lime juice (14580 ng/g), grapefruit juice (95341 ng/g), and limes (9151 ng/g). Bergamottin was found in the greatest proportion of foods sampled (23 of 29), followed by bergapten (19 of 29) and 6'7'-dihydroxybergamottin (16 of 29). These measurements will enable more accurate estimation of dietary furocoumarin exposure and will strengthen future epidemiological work investigating the relationships between furocoumarin intake and health outcomes.

Furocoumarin Kinetics in Plasma and Urine of Healthy Adults Following Consumption of Grapefruit (Citrus paradisi Macf.) and Grapefruit Juice

Furocoumarins are a class of organic compounds found in a variety of vegetables and fruits. Relatively little is known about the absorption and excretion of these compounds following ingestion. The objective of this study was to identify furocoumarins in grapefruit and grapefruit juice and observe their kinetics in blood and urine. The furocoumarins detected in grapefruit using UPLC-MS/MS were bergamottin, 6',7'-dihydroxybergamottin (6',7'-DHB), epoxybergamottin, and bergaptol. Bergamottin, 6',7'-DHB, bergaptol, and bergapten were detected in grapefruit juice. In this study of 6 males and 3 females, only bergamottin and 6',7'-DHB were detected in plasma, whereas in urine, four distinct furocoumarin metabolites as well as bergaptol, 6',7'-DHB, 8-methoxypsoralen (8-MOP), bergamottin, and psoralen were identified. Following grapefruit ingestion, furocoumarins were detectable in plasma as early as 15 min and in urine within 1 h. They remained in plasma for up to 3 or more hours and in urine as late as 24 h.

Morphea - selected local treatment methods and their effectiveness

Localised scleroderma is an uncommon connective tissue disease of multifactorial aetiology occurring in the paediatric and adult population. It is relatively difficult to conduct any research on the subject of this disease entity treatment due to the low number of patients suffering from morphea, a tendency of the disease to remit spontaneously, and not yet well recognised aetiology. Hence, there has been developed no causal treatment of well-proven effectiveness, and schedules of symptomatic therapy are not yet clearly determined. The paper depicts most widely used topical treatment methods in morphea therapy, which due to minor risk of systemic adverse effects seem to be a beneficial therapeutic alternative. The main aim of this article was to analyse different topical treatment options used in localised scleroderma therapy and to indicate the most appropriate, safe, and effective one.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Psoriasis, psoriatic arthritis, and rheumatoid arthritis: Is all inflammation the same?

OBJECTIVES

To review the pathophysiology, co-morbidities, and therapeutic options for psoriasis, psoriatic arthritis and rheumatoid arthritis in order to further understand the similarities and differences in treatment paradigms in the management of each disease. New targets for individualized therapeutic decisions are also identified with the aim of improving therapeutic outcome and reducing toxicity.

SEARCH STRATEGY

Using the PubMed database, we searched literature published from 2000 to 2015 using combinations of the key words "psoriasis," "psoriatic arthritis," "rheumatoid arthritis," "pathogenesis," "immunomodulation," and "treatment."

INCLUSION AND EXCLUSION CRITERIA

This was a non-systematic review and there were no formal inclusion and exclusion criteria.

DATA EXTRACTION

Abstracts identified in the search were screened for relevance and articles considered appropriate evaluated further. References within these selected articles were also screened. Information was extracted from 198 articles for inclusion in this report.

DATA SYNTHESIS

There was no formal data synthesis. Articles were reviewed and summarized according to disease area (psoriasis, psoriatic arthritis, and rheumatoid arthritis).

HEADLINE RESULTS

The pathophysiology of psoriasis, psoriatic arthritis, and rheumatoid arthritis involves chronic inflammation mediated by pro-inflammatory cytokines. Dysfunction in integrated signaling pathways affecting different constituents of the immune system result in varying clinical features in the three diseases. Co-morbidities, including cardiovascular disease, malignancies, and non-alcoholic fatty liver disease are increased. Increased understanding of the immunopathogenesis allowed development of targeted treatments; however, despite a variety of potentially predictive genetic, protein and cellular biomarkers, there is still significant unmet need in these three inflammatory disorders.

Mycosis fungoides patient accompanied actinic keratosis, actinic keratosis with squamous cell carcinoma transformation, and porokeratosis after NBUVB therapy - 1st case report and review of the literature

INTRODUCTION

Mycosis fungoides (MF) is the most common form of primary cutaneous T cell lymphoma. Narrowband ultraviolet B light (NBUVB) is used increasingly in treating MF because of its good toleration and well-established management.

CONCERNS

To discuss the risk factors and underlying pathogenic factors in the patients with secondary skin diseases after NBUVB therapy.

METHODS

We report in details the first case of a patient with MF accompanied with actinic keratosis (AK), AK with squamous cell carcinoma (SCC) transformation and porokeratosis after NBUVB therapy. Meanwhile, Sequence variants in tumor suppressor p53 gene in the patient's specimens were detected. A literature search of the key word "narrowband ultraviolet B light "and "side effects" was performed on PubMed, 14 cases of this entity were found. A total of 15 patients including our case were reviewed in this study and meaningful conclusion could be drawn.

OUTCOMES

The mean age at diagnosis of secondary skin dermatoses after NBUVB therapy was 62.08 years with a male to female ratio of 2:1. The cases were reported more in Europeans than in Asians (2.75:1), and the Fitzpatrick skin type was mainly Ito III (12/15). The mean cumulative number and cumulative dose of UVB treatments were 43.71 and 42, 400 (mJ/cm), respectively. There was a positive relationship between Fitzpatrick skin type and cumulative dose of UVB treatments. Among the secondary skin diseases after NBUVB treatment, 12 were tumors, 2 were non-tumorous dermatoses. Only our patient presented with both. By polymerase chain reaction-single nucleotide polymorphism (PCR-SNP) analysis, C-G mutation of exon 4 of p53 was found in AK and MF specimens in our patient.

CONCLUSION

To our knowledge, our case is the first MF patient accompanied with AK, AK with SCC transformation and Porokeratosis after NBUVB treatment. Lower Fitzpatrick skin type may be the risk factor of secondary skin diseases after NBUVB treatment.

Safety of Efalizumab in Patients with Moderate to Severe Chronic Plaque Psoriasis: Review of Clinical Data. Part II

Background:

The efficacy and safety of efalizumab have been evaluated in multiple clinical trials. ObjectiveThe purpose of this review is to provide an overview of the safety profile of efalizumab during the clinical trials.

Methods:

Twelve-week data from four placebo-controlled trials were pooled and analyzed. Data from patients receiving 13—60 weeks of efalizumab therapy were pooled to evaluate longer-term safety.

Results:

The most common adverse events were mild to moderate, self-limiting, flulike symptoms that were most frequent following the first two efalizumab doses; by the third dose the incidence was comparable to placebo. Serious adverse events were observed in 2.2% and 1.7% of efalizumab- and placebo-treated patients, respectively. Nonserious adverse events leading to withdrawal were infrequent and similar to placebo (2.8% vs 1.8%). There does not appear to be increased risk of end-organ toxicity, infection, or malignancy in efalizumab-treated patients.

Conclusion:

Efalizumab was well tolerated, with a favorable safety profile.

Increase in the photoreactivity of uracil derivatives by doubling thionation

The ability of 4-thiouracil to strongly absorb UVA radiation and to populate a reactive triplet state in high yield has enabled its use as a versatile photocrosslinker for nearly 50 years. In this contribution, we present a detailed spectroscopic and photochemical investigation of the 2-thiouracil, 4-thiouracil, and 2,4-dithiouracil series in an effort to further advance this chemistry and to scrutinize the photoreactivity of 2,4-dithiouracil. Our results reveal that excitation of 2,4-dithiouracil leads to intersystem crossing to the triplet manifold in 220 ± 40 fs, which enables the population of the reactive triplet state with near unity yield (ΦT = 0.90 ± 0.15) and ultimately leads to a ca. 50% singlet oxygen generation (ΦΔ = 0.49 ± 0.02)-one of the highest singlet oxygen yields reported to date for a photoexcited thiobase. In addition, the long-lived triplet state of 2,4-dithiouracil reacts efficiently with the nucleic acid base adenine 5'-monophosphate through a direct, oxygen-independent photocycloaddition mechanism and at a rate that is at least 3-fold faster than that of 4-thiouracil under equal conditions. The new physico-chemical insights reported for these RNA-thiobase derivatives are compared to those of the DNA and RNA bases and the DNA-thiobase derivatives. Furthermore, the strong near-visible absorption and increased photoreactivity measured for 2,4-dithiouracil lays a solid foundation for developing RNA-targeted photocrosslinking and phototherapeutic agents that are more effective than those currently available.

Serotonin signalling is crucial in the induction of PUVA-induced systemic suppression of delayed-type hypersensitivity but not local apoptosis or inflammation of the skin

Psoralen and UVA (PUVA) has immunosuppressive and proapoptotic effects, which are thought to be responsible alone or in combination for its therapeutic efficacy. However, the molecular mechanism by which PUVA mediates its effects is not well understood. Activation of the serotonin (5-hydroxytryptamine, 5-HT) pathway has been suggested to be involved in the modulation of T-cell responses and found to mediate UVB-induced immune suppression. In particular, the activation of the 5-HT2A receptor has been proposed as one mechanism responsible for UV-induced immune suppression. We therefore hypothesized that 5-HT may play a role in PUVA-induced effects. The model of systemic suppression of delayed-type hypersensitivity (DTH) to Candida albicans was used to study immune function after exposure of C3H and KIT(W) (-Sh/W-Sh) mice to a minimal inflammatory dose of topical PUVA. The intra-peritoneal injection of the 5-HT2 receptor antagonist ketanserin or cyproheptadine or an anti-5-HT antibody immediately before PUVA exposure entirely abrogated suppression of DTH but had no significant effect on inflammation, as measured by swelling and cellular infiltration of the skin, and apoptosis as determined by the number of sunburn cells in C3H mice. Importantly, the systemic injection of 5-HT recapitulated PUVA immune suppression of DTH but did not induce inflammation or apoptosis in the skin. KIT(W) (-Sh/W-Sh) mice (exhibiting myelopoietic abnormalities, including lack of 5-HT-containing mast cells) were resistant to PUVA-induced suppression of DTH but not local skin swelling. Thus, this points towards a crucial role of 5-HT signalling in PUVA-induced immune suppression but not inflammation or apoptosis in situ in the skin.

Clinical and economic review of secukinumab for moderate-to-severe plaque psoriasis

Secukinumab represents the first IL-17A antagonist among the available biologic therapies approved for moderate-to-severe plaque psoriasis management. Secukinumab demonstrated greater efficacy over placebo, etanercept and ustekinumab in patients that had limited benefit from non-biologic systemic therapies and phototherapy. Despite standard-of-care systemic therapies being more likely to be cost-effective at this time, a Canadian cost-utility analysis found secukinumab to display benefit in quality-of-life gains in moderate-to-severe plaque psoriasis patients, and greater cost-effectiveness when compared to other biologic systemic therapies. Determination of the true economic value of secukinumab amongst the available therapies for moderate-to-severe plaque psoriasis will require continued economic evaluation.