Grenz ray therapy

Grenz ray therapy in disseminated superficial actinic porokeratosis: A case series of 17 patients

The treatments available for disseminated superficial actinic porokeratosis (DSAP) have been limited and have variable efficacy. We report the largest case series to date of the use of Grenz ray therapy in 17 patients with DSAP. There was at least 50% improvement in DSAP lesions in all cases. Erythema, itching and burning were common side effects of Grenz ray therapy. We believe that Grenz ray therapy may be an effective treatment option for patients with DSAP.

Few X-ray and PUVA treatments accelerate photocarcinogenesis in hairless mice

PUVA is a treatment that combines oral methoxypsoralen (8-MOP) with ultraviolet radiation A (UVA). It is used for severe psoriasis and the early stages of T-cell lymphoma. X-rays are an effective treatment for skin cancers. Both treatments are in higher doses used to treat skin malignancies and simultaneously increase the risk of keratinocyte cancer. The main objective of this study was to test whether a few PUVA or X-ray treatments could delay the development of ultraviolet radiation (UVR)-induced skin tumors in a well-established hairless mouse model. Three groups of immunocompetent mice (total, N = 75) were included in the study. All groups were UVR-exposed during the study period. In addition, one group was treated with PUVA and another group was treated with X-rays at days 45, 52, 90 and 97. A control group was treated with UVR only. We recorded when the first, second and third skin tumors were induced in each mouse. Skin tumors developed significantly earlier in both the PUVA and X-ray groups (median, 188 days) than in the control mice (median, 215 days; p < 0.001). Therefore, a few X-ray and PUVA treatments both significantly accelerated the development of skin tumors in hairless mice, compared to UVR controls. Neither treatment showed a delay of UVR-induced skin tumors and caution should be exercised before applying these treatments to sun-damaged skin.

Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy

Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 3.2% of the world's population. In this section of the guidelines of care for psoriasis, we will focus the discussion on ultraviolet (UV) light-based therapies, which include narrowband and broadband UVB, UVA in conjunction with photosensitizing agents, targeted UVB treatments such as with an excimer laser, and several other modalities and variations of these core phototherapies, including newer applications of pulsed dye lasers, intense pulse light, and light-emitting electrodes. We will provide an in-depth, evidence-based discussion of efficacy and safety for each treatment modality and provide recommendations and guidance for the use of these therapies alone or in conjunction with other topical and/or systemic psoriasis treatments.

Low energy X-ray (grenz ray) treatment of purified islets prior to allotransplant markedly decreases passenger leukocyte populations

Grenz rays, or minimally penetrating X-rays, are known to be an effective treatment of certain recalcitrant immune-mediated skin diseases, but their use in modulating allograft rejection has not been tested. We examined the capacity of grenz ray treatment to minimize islet immunogenicity and extend allograft survival in a mouse model. In a preliminary experiment, 1 of 3 immunologically intact animals demonstrated long-term acceptance of their grenz ray treated islet allograft. Further experiments revealed that 28.6% (2 of 7) grenz ray treated islet allografts survived >60 d. A low dose of 20Gy, was important; a 4-fold increase in radiation resulted in rapid graft failure, and transplanting a higher islet mass did not alter this outcome. To determine whether increased islet allograft survival after grenz treatment would be masked by immunosuppression, we treated the recipients with CTLA-4 Ig, and found an additive effect, whereby 17.5% more animals accepted the graft long-term versus those with CTLA-4 Ig alone. Cell viability assays verified that islet integrity was maintained after treatment with 20Gy. As well, through splenocyte infiltration analysis, donor CD4+ T cell populations 24-hours after transplant were decreased by more than16-fold in recipients receiving irradiated islets compared with control. Donor CD8+ T cell populations, although less prevalent, decreased in all treatment groups compared with control. Our results suggest that brief treatment of isolated islets with low energy grenz rays before allotransplantation can significantly reduce passenger leukocytes and promote graft survival, possibly by inducing donor dendritic cells to differentiate toward a tolerogenic phenotype.

Review: the reemergence of brachytherapy as treatment for non-melanoma skin cancer

Electronic brachytherapy (EBT) has seen a significant rise in use over the past few years in treating non-melanoma skin cancer (NMSC). However, the current literature in EBT remains scarce. Existing data on high-dose rate brachytherapy (HDR-BT) with surface applicators is often used to justify its efficacy and safety. In this review we study the two treatment modalities on their efficacy in treating NMSC and we explore the reasons behind the recent uprise in EBT. A literature review using PubMed was performed for articles published until January 2017 studying efficacy of HDR-BT and EBT for treating NMSC. HDR-BT demonstrated effective local control ranging from 96.2% to 100% up to 66 months of follow-up with acceptable cosmesis. For EBT, local control rates ranged from 90% to 100% with generally favorable tolerance and cosmesis outcome after roughly one year. While longer term data on EBT is needed, its short term efficacy shows promise as a possible alternative to surgery or other radiation therapy in a select group of patients.

Custom-made micro applicators for high-dose-rate brachytherapy treatment of chronic psoriasis

Purpose

In this study, we present the treatment of the psoriatic nail beds of patients refractory to standard therapies using high-dose-rate (HDR) brachytherapy. The custom-made micro applicators (CMMA) were designed and constructed for radiation dose delivery to small curvy targets with complicated topology. The role of the HDR brachytherapy treatment was to stimulate the T cells for an increased immune response.

Material and methods

The patient diagnosed with psoriatic nail beds refractory to standard therapies received monthly subunguinal injections that caused significant pain and discomfort in both hands. The clinical target was defined as the length from the fingertip to the distal interphalangeal joint. For the accurate and reproducible setup in the multi-fractional treatment delivery, the CMMAs were designed. Five needles were embedded into the dense plastic mesh and covered with 5 mm bolus material for each micro applicator. Five CMMAs were designed, resulting in the usage of 25 catheters in total.

Results

The prescription dose was planned to the depth of the anterior surface of the distal phalanx, allowing for the sparing of the surrounding tissue. The total number of the active dwell positions was 145 with step size of 5 mm. The total treatment time was 115 seconds with a 7.36 Ci activity of the ¹⁹²Ir source. The treatment resulted in good pain control. The patient did not require further injections to the nail bed. After this initial treatment, additional two patients with similar symptoms received HDR brachytherapy. The treatment outcome was favorable in all cases.

Conclusions

The first HDR brachytherapy treatment of psoriasis of the nail bed is presented. The initial experience revealed that brachytherapy treatment was well-tolerated and resulted in adequate control of the disease. A larger cohort of patients will be required for additional conclusions related to the long-term clinical benefits.

Six years' experience of grenz ray therapy for the treatment of inflammatory skin conditions

BACKGROUND

In 2008, Ninewells Hospital became the first centre in the UK to offer grenz rays as a treatment for inflammatory dermatoses. Since then, 122 courses have been administered for the following conditions; scalp psoriasis (n = 36), nail dystrophies (n = 27), hyperkeratotic eczema/psoriasis (n = 22), palmoplantar pustulosis (n = 9), perianal pruritus (n = 9), warts (n = 4) and other conditions (n = 15).

AIM

To review all patients who received grenz rays in order to determine which conditions have been treated successfully and to estimate remission times.

METHOD

Patient notes were reviewed, and follow-up was supplemented by subsequent dermatology clinic letters and telephone consultation.

RESULTS

For scalp psoriasis, clearance was achieved with 13 courses, marked improvement with 19, minimal improvement in 3 and no change with 1. Treatment of palmoplantar psoriasis/hyperkeratotic eczema showed clearance with 7 courses, marked improvement with 9, minimal change with 2 and no change with 4. Of the courses for nail dystrophies (mainly psoriasis), clearance occurred with 1, marked improvement with 7, minimal change with 8 and no change with 11. In addition to immediate outcomes, the remission times were also evaluated. For scalp psoriasis, only 8 of the initial 32 patients still had clearance or marked improvement at the most recent follow-up. For nail dystrophy, 3 of 8 patients remained in remission, while for hyperkeratotic eczema/psoriasis, 7 of the initial 16 patients who had clearance or marked improvement had sustained this improvement, and only 1 patient with palmoplantar pustulosis still had clearance at the most recent follow-up.

CONCLUSIONS

Grenz ray therapy is an effective treatment for some chronic inflammatory skin conditions that are resistant to routine therapies. The period of remission for scalp psoriasis was good for some patients but disappointingly short for others. Future studies involving different cumulative doses with subsets of different dose fractionations may help optimize treatment regimens.

The effectiveness of grenz ray therapy for chronic dermatoses of the hands and feet

BACKGROUND

Grenz ray therapy (GRT) has been used for inflammatory and neoplastic dermatologic diseases for over 100 years. Its use is declining, possibly because of the difficulties maintaining radiation certification and insurance coverage.

OBJECTIVE

The aim of this study is to evaluate the safety and effectiveness of GRT in chronic inflammatory dermatoses of the hands and feet.

METHODS

We performed a retrospective chart review of patients treated with GRT at the Oregon Health & Science University from 2006 to 2009. Candidates identified for the study were then mailed questionnaires to supplement data acquired from chart review.

RESULTS

Most patients (73%; 95% confidence interval [CI], 65%-80%) experienced at least moderate improvement. This improvement persisted for at least 1 month in 66% of patients (95% CI, 57%-74%), with 18 patients (23%; 95% CI, 15%-33%) clear for over 1 year. Minimal adverse effects were reported, and most patients (63%; 95% CI, 52%-72%) stated that they would repeat GRT if available.

CONCLUSIONS

Grenz ray therapy seems to be a safe and effective modality for chronic hand and foot dermatoses with some patients experiencing prolonged remissions. Grenz ray therapy, when available, should be considered before the use of systemic agents, which are often associated with higher costs and potential toxicities.

Radiation Therapy for Chronic Vesicular Hand Dermatitis

BACKGROUND

Chronic vesicular hand dermatitis is a chronic disease that can be debilitating for patients, and many treatment options do not provide lasting remission.

OBJECTIVE

We attempted to determine the efficacy of megavoltage irradiation in the treatment of this disease.

METHODS

Between July 2001 and March 2005, 9 patients with severe chronic vesicular hand dermatitis had megavoltage radiation therapy to their sites of disease. Eight pairs of hands and seven pairs of feet were irradiated (15 total sites).

RESULTS

All patients had an improvement in their disease during the course of radiation therapy. Patients were followed after radiation therapy for a median follow-up time of 20.2 months (range, 1 to 45 months). The disease completely resolved in 7 of the 15 (47%) sites irradiated. There was a decrease in the severity or frequency of flare-ups at the other 8 sites (53%).

CONCLUSION

Megavoltage radiation therapy may be effective in the treatment of chronic vesicular hand dermatitis and may provide durable remissions in some patients.

Therapeutic options for chronic hand dermatitis

Hand dermatitis is a common skin condition that often has a chronic and/or relapsing clinical course. Several clinical forms of hand dermatitis have been described, including contact (i.e., allergic and irritant), hyperkeratotic (i.e., psoriasiform or tylotic), frictional, nummular, atopic, pompholyx (i.e., dyshidrosis), and chronic vesicular hand dermatitis. In the present review, therapeutic options for these types of hand dermatitis are discussed in detail, focusing on treatments for recalcitrant hand dermatitis.