Phototherapy: how does UV work?

Phototherapy for age-related brain diseases: Challenges, successes and future

Brain diseases present a significant obstacle to both global health and economic progress, owing to their elusive pathogenesis and the limited effectiveness of pharmaceutical interventions. Phototherapy has emerged as a promising non-invasive therapeutic modality for addressing age-related brain disorders, including stroke, Alzheimer's disease (AD), and Parkinson's disease (PD), among others. This review examines the recent progressions in phototherapeutic interventions. Firstly, the article elucidates the various wavelengths of visible light that possess the capability to penetrate the skin and skull, as well as the pathways of light stimulation, encompassing the eyes, skin, veins, and skull. Secondly, it deliberates on the molecular mechanisms of visible light on photosensitive proteins, within the context of brain disorders and other molecular pathways of light modulation. Lastly, the practical application of phototherapy in diverse clinical neurological disorders is indicated. Additionally, this review presents novel approaches that combine phototherapy and pharmacological interventions. Moreover, it outlines the limitations of phototherapeutics and proposes innovative strategies to improve the treatment of cerebral disorders.

Narrowband ultraviolet B phototherapy for pityriasis lichenoides: A real-life experience

INTRODUCTION

Pityriasis lichenoides (PL) is a papulosquamous disease affecting both children and adults, for which narrowband-UVB (NB-UVB) phototherapy is regarded as a commonly used treatment option. The aim of this study was to investigate the efficacy of NB-UVB phototherapy in the management of PL and to compare response rates in pediatric and adult age groups.

MATERIALS AND METHODS

This observational, retrospective study included 20 PL patients (12 pityriasis lichenoides chronica; PLC, 8 pityriasis lichenoides et varioliformis acuta; PLEVA) who failed to respond to other treatment modalities. The data for this study were collected retrospectively from patient follow-up forms in the phototherapy unit.

RESULTS

A complete response (CR) was obtained in all pediatric patients with PL, while 53.8% of adult patients had achieved CR. The mean cumulative dose required to achieve the CR was higher in pediatric patients than adult patients with PL (p < .05). The CR was achieved in 6 (75%) of 8 PLEVA patients, while 8 (66.7%) of 12 PLC patients had reached to CR. The mean number of exposures for patients with PLC to achieve a CR was higher than patients with PLEVA (p < .05). Erythema was the most common adverse effect during phototherapy particularly in 5 (35.7%) of the patients with PL who had achieved CR.

CONCLUSIONS

NB-UVB is an effective and well-tolerated treatment option for PL especially in diffuse types. A higher response can be obtained in children with higher cumulative dose. Patients with PLC may require more exposures for CR than patients with PLEVA.

Phototherapy for atopic eczema

BACKGROUND

Atopic eczema (AE), also known as atopic dermatitis, is a chronic inflammatory skin condition that causes significant burden. Phototherapy is sometimes used to treat AE when topical treatments, such as corticosteroids, are insufficient or poorly tolerated.

OBJECTIVES

To assess the effects of phototherapy for treating AE.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov to January 2021.

SELECTION CRITERIA

We included randomised controlled trials in adults or children with any subtype or severity of clinically diagnosed AE. Eligible comparisons were any type of phototherapy versus other forms of phototherapy or any other treatment, including placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. For key findings, we used RoB 2.0 to assess bias, and GRADE to assess certainty of the evidence. Primary outcomes were physician-assessed signs and patient-reported symptoms. Secondary outcomes were Investigator Global Assessment (IGA), health-related quality of life (HRQoL), safety (measured as withdrawals due to adverse events), and long-term control.

MAIN RESULTS

We included 32 trials with 1219 randomised participants, aged 5 to 83 years (mean: 28 years), with an equal number of males and females. Participants were recruited mainly from secondary care dermatology clinics, and study duration was, on average, 13 weeks (range: 10 days to one year). We assessed risk of bias for all key outcomes as having some concerns or high risk, due to missing data, inappropriate analysis, or insufficient information to assess selective reporting. Assessed interventions included: narrowband ultraviolet B (NB-UVB; 13 trials), ultraviolet A1 (UVA1; 6 trials), broadband ultraviolet B (BB-UVB; 5 trials), ultraviolet AB (UVAB; 2 trials), psoralen plus ultraviolet A (PUVA; 2 trials), ultraviolet A (UVA; 1 trial), unspecified ultraviolet B (UVB; 1 trial), full spectrum light (1 trial), Saalmann selective ultraviolet phototherapy (SUP) cabin (1 trial), saltwater bath plus UVB (balneophototherapy; 1 trial), and excimer laser (1 trial). Comparators included placebo, no treatment, another phototherapy, topical treatment, or alternative doses of the same treatment. Results for key comparisons are summarised (for scales, lower scores are better): NB-UVB versus placebo/no treatment There may be a larger reduction in physician-assessed signs with NB-UVB compared to placebo after 12 weeks of treatment (mean difference (MD) -9.4, 95% confidence interval (CI) -3.62 to -15.18; 1 trial, 41 participants; scale: 0 to 90). Two trials reported little difference between NB-UVB and no treatment (37 participants, four to six weeks of treatment); another reported improved signs with NB-UVB versus no treatment (11 participants, nine weeks of treatment). NB-UVB may increase the number of people reporting reduced itch after 12 weeks of treatment compared to placebo (risk ratio (RR) 1.72, 95% CI 1.10 to 2.69; 1 trial, 40 participants). Another trial reported very little difference in itch severity with NB-UVB (25 participants, four weeks of treatment). The number of participants with moderate to greater global improvement may be higher with NB-UVB than placebo after 12 weeks of treatment (RR 2.81, 95% CI 1.10 to 7.17; 1 trial, 41 participants). NB-UVB may not affect rates of withdrawal due to adverse events. No withdrawals were reported in one trial of NB-UVB versus placebo (18 participants, nine weeks of treatment). In two trials of NB-UVB versus no treatment, each reported one withdrawal per group (71 participants, 8 to 12 weeks of treatment). We judged that all reported outcomes were supported with low-certainty evidence, due to risk of bias and imprecision. No trials reported HRQoL. NB-UVB versus UVA1 We judged the evidence for NB-UVB compared to UVA1 to be very low certainty for all outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (MD -2.00, 95% CI -8.41 to 4.41; 1 trial, 46 participants; scale: 0 to 108), or patient-reported itch after six weeks (MD 0.3, 95% CI -1.07 to 1.67; 1 trial, 46 participants; scale: 0 to 10). Two split-body trials (20 participants, 40 sides) also measured these outcomes, using different scales at seven to eight weeks; they reported lower scores with NB-UVB. One trial reported HRQoL at six weeks (MD 2.9, 95% CI -9.57 to 15.37; 1 trial, 46 participants; scale: 30 to 150). One split-body trial reported no withdrawals due to adverse events over 12 weeks (13 participants). No trials reported IGA. NB-UVB versus PUVA We judged the evidence for NB-UVB compared to PUVA (8-methoxypsoralen in bath plus UVA) to be very low certainty for all reported outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (64.1% reduction with NB-UVB versus 65.7% reduction with PUVA; 1 trial, 10 participants, 20 sides). There was no evidence of a difference in marked improvement or complete remission after six weeks (odds ratio (OR) 1.00, 95% CI 0.13 to 7.89; 1 trial, 9/10 participants with both treatments). One split-body trial reported no withdrawals due to adverse events in 10 participants over six weeks. The trials did not report patient-reported symptoms or HRQoL. UVA1 versus PUVA There was very low-certainty evidence, due to serious risk of bias and imprecision, that PUVA (oral 5-methoxypsoralen plus UVA) reduced physician-assessed signs more than UVA1 after three weeks (MD 11.3, 95% CI -0.21 to 22.81; 1 trial, 40 participants; scale: 0 to 103). The trial did not report patient-reported symptoms, IGA, HRQoL, or withdrawals due to adverse events. There were no eligible trials for the key comparisons of UVA1 or PUVA compared with no treatment. Adverse events Reported adverse events included low rates of phototoxic reaction, severe irritation, UV burn, bacterial superinfection, disease exacerbation, and eczema herpeticum.

AUTHORS' CONCLUSIONS

Compared to placebo or no treatment, NB-UVB may improve physician-rated signs, patient-reported symptoms, and IGA after 12 weeks, without a difference in withdrawal due to adverse events. Evidence for UVA1 compared to NB-UVB or PUVA, and NB-UVB compared to PUVA was very low certainty. More information is needed on the safety and effectiveness of all aspects of phototherapy for treating AE.

Differences in phototherapy among skin diseases and genders in real-life conditions-A retrospective analysis of the cumulative doses, numbers of sessions, side effects and costs in 561 patients

BACKGROUND

Phototherapy has been a mainstay therapy for dermatological diseases since more than a century. Although phototherapy is still extensively used and some recommendations exist, only scarce data are available addressing disease-specific differences in cumulative doses, treatment durations and costs. Knowledge of such differences could help to avoid over-/undertreatment, predict treatment duration and costs. Therefore, we sought to determine differences in cumulative doses, numbers of sessions, side effects and costs among different skin diseases and genders in real-life conditions.

METHODS

In this single-centre, retrospective study, patients treated with phototherapy between March 2014 and April 2019 were classified into seven diagnostic groups and analysed according to the study goals.

RESULTS

Out of 561 patients (age 53.9 ± 20.3 yrs; 52.9% females), 83.7% percent were treated with cabin NB-UVB (mean cumulative dose 17.79 ± 17.11 J/cm² ). Patients with vitiligo and psoriasis were treated with significantly higher cumulative NB-UVB doses (cabin, local) in comparison with the five other diagnostic groups as were males in comparison with females. Consequently, significantly higher UV-related costs resulted in patients with vitiligo, psoriasis and males. Patients with atopic dermatitis and pruritus were treated with significantly higher cumulative UVA1 doses compared to patients with non-atopic eczema. The complication rate (pooled from all UV modalities) in our population was 3.8% (erythema 3.4%, aggravated itch 0.4% and worsening of symptoms 0.2%).

CONCLUSIONS

Our results demonstrate that cumulative doses and phototherapy-related costs vary strongly among skin diseases-a fact not adequately considered in recommendations. A more disease-specific stratification of phototherapy could not only help to optimize outcomes, but also to facilitate comparability of clinical trials using phototherapy.

Narrowband ultraviolet B therapy for refractory immune-related lichenoid dermatitis on PD-1 therapy: a case report

Treatment with programmed cell death 1 inhibitors is associated with a wide range of cutaneous immune-related adverse events, with lichenoid eruptions representing one of the major cutaneous toxicities. We describe the case of an 81-year-old man with metastatic melanoma treated with pembrolizumab who subsequently developed a delayed-onset generalized lichenoid dermatitis. After failing multiple lines of systemic immunosuppression, narrowband ultraviolet B (NBUVB) phototherapy three times per week for 17 sessions resulted in a significant clinical response in his cutaneous eruption and was well tolerated. NBUVB is a safe, lower-cost modality that induces local, skin-specific immunosuppression without the toxicities of traditional systemic immunosuppressive agents. To date, this is the first report of use of NBUVB in immune-related lichenoid dermatitis resistant to multiple standard therapies.

Combination of targeted UVB phototherapy and calcipotriene versus targeted UVB alone in psoriasis: systematic review and meta-analysis of randomized controlled trials

Background: Targeted UVB and topical calcipotriene have frequently been used in the treatment of psoriasis, but the joint effect of calcipotriene and targeted UVB has been controversial.Objectives: The purpose of this study was to systematically evaluate whether the efficacy of the combined use of targeted UVB and calcipotriene is superior to the targeted UVB alone.Methods: We performed systematic review and meta-analysis of randomized controlled trials (RCTs) in patients with plaque-type psoriasis through searching the defined key words in the PubMed, EMBase, and Cochrane Central Register databases. Pooled mean difference of the Psoriasis Area and Severity Index (PASI) relative change (%) was estimated using a random effect model. The quality of included studies and publication bias were assessed using the Jadad scale and the Egger's test, respectively.Results: A total of five RCTs including 182 patients were included in the systematic review. The mean difference of the PASI relative change (%) between the combined therapy versus the targeted UVB alone was -22.68 (95%CI: -37.12 to -8.24; p = .002). Publication bias was not supported by the Egger's test (p = .424).Conclusion: Addition of calcipotriene ointment may improve the efficacy of the targeted UVB phototherapy in the treatment of plaque-type psoriasis.

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.

Treatment of Hailey-Hailey disease with narrowband phototherapy and acitretin: A case report

The Hailey–Hailey disease, or familial benign chronic pemphigus, is an autosomal dominant genodermatosis affecting mainly intertriginous areas. It manifests itself in painful blisters, erosions, and cracks and has a chronic course with frequent flares, significantly impacting patients’ quality of life. Presently, there is no cure, but multiple treatment modalities are available. Most evidence supports treatment with topical steroids and antimicrobials. Treatment of recalcitrant disease has been shown to benefit from the addition of oral antibiotics, Naltrexone, systemic retinoids, botulinum toxin A injections, laser treatment, and surgical excision. We describe a case of refractory Hailey–Hailey disease for which most of the abovementioned options failed, but which demonstrated significant improvement following a combination of oral acitretin and narrowband ultraviolet-B phototherapy. To achieve remission, the patient received 30 sessions three times per week with the increment of 20 mJ/cm² per session and oral acitretin 25 mg PO daily.

Effects of irradiation with narrowband-ultraviolet B on up-regulation of histamine H1 receptor mRNA and induction of apoptosis in HeLa cells and nasal mucosa of rats

Narrowband-ultraviolet B (NB-UVB) phototherapy is used for the treatment of atopic dermatitis. Previously, we reported that irradiation with 200 mJ/cm² of 310 nm NB-UVB suppressed phorbol-12-myristate-13-acetate (PMA)-induced up-regulation of histamine H₁ receptor (H1R) gene expression without induction of apoptosis in HeLa cells. However, the effect of NB-UVB irradiation on nasal symptoms is still unclear. Here, we show that low dose irradiation with 310 nm NB-UVB alleviates nasal symptoms in toluene 2,4-diisocyanate (TDI)-sensitized allergy model rats. Irradiation with 310 nm NB-UVB suppressed PMA-induced H1R mRNA up-regulation in HeLa cells dose-dependently at doses of 75-200 mJ/cm² and reversibly at a dose of 150 mJ/cm² without induction of apoptosis. While, at doses of more than 200 mJ/cm², irradiation with 310 nm NB-UVB induced apoptosis. Western blot analysis showed that the suppressive effect of NB-UVB irradiation on H1R gene expression was through the inhibition of ERK phosphorylation. In TDI-sensitized rat, intranasal irradiation with 310 nm NB-UVB at an estimated dose of 100 mJ/cm² once a day for three days suppressed TDI-induced sneezes and up-regulation of H1R mRNA in nasal mucosa without induction of apoptosis. These findings suggest that repeated intranasal irradiation with low dose of NB-UVB could be clinically used as phototherapy of AR.

Irradiation with 310 nm and 340 nm ultraviolet light-emitting-diodes can improve atopic dermatitis-like skin lesions in NC/Nga mice

Ultraviolet (UV) light produces an immunomodulatory effect on the skin and is widely used for the treatment of chronic inflammatory skin diseases. UV light emitting diodes (UV-LEDs) are a new and promising source of UV radiation. However, their mechanism of action remains largely unknown. In this study, we tested the safety and effectiveness of UV-LED irradiation for the treatment of atopic dermatitis (AD) in an NC/Nga mouse model. Mice were divided into seven groups of eight mice each. Application of Dermatophagoides farinae (Df) extract ointment for four weeks induced AD-like skin lesions. Subsequently, the mice were exposed to UV-LEDs, narrow band UVB, or UVA irradiation three times per week. We assessed the immunosuppressive effects of 310 nm (50 mJ cm-2) and 340 nm (5 J cm-2) UV-LED irradiation. Histological analyses using hematoxylin-eosin, toluidine blue, and immunohistochemical staining were performed. In addition, the serum levels of IgE, inflammatory cytokines and chemokines were measured using enzyme-linked immunosorbent assays (ELISAs). UV-LED irradiation significantly alleviated AD-like skin symptoms, including edema, erythema, dryness, and itching, by modulating Th1 and Th2 responses, transepidermal water loss (TEWL), and scratching behavior in NC/Nga mice. These results suggest that UV-LEDs can improve the treatment of inflammatory skin diseases.

Treatment of seborrheic dermatitis: a comprehensive review

Seborrheic dermatitis (SD) is a chronic, recurring inflammatory skin disorder that manifests as erythematous macules or plaques with varying levels of scaling associated with pruritus. The condition typically occurs as an inflammatory response to Malassezia species and tends to occur on seborrheic areas, such as the scalp, face, chest, back, axilla, and groin areas. SD treatment focuses on clearing signs of the disease; ameliorating associated symptoms, such as pruritus; and maintaining remission with long-term therapy. Since the primary underlying pathogenic mechanisms comprise Malassezia proliferation and inflammation, the most commonly used treatment is topical antifungal and anti-inflammatory agents. Other broadly used therapies include lithium gluconate/succinate, coal tar, salicylic acid, selenium sulfide, sodium sulfacetamide, glycerin, benzoyl peroxide, aloe vera, mud treatment, phototherapy, among others. Alternative therapies have also been reported, such as tea tree oil, Quassia amara, and Solanum chrysotrichum. Systemic therapy is reserved only for widespread lesions or in cases that are refractory to topical treatment. Thus, in this comprehensive review, we summarize the current knowledge on SD treatment and attempt to provide appropriate directions for future cases that dermatologists may face.

Folliculotropic Mycosis Fungoides in 20 Korean Cases: Clinical and Histopathologic Features and Response to Ultraviolet A-1 and/or Photodynamic Therapy

Background

Folliculotropic mycosis fungoides (FMF) is a variant of mycosis fungoides (MF) that is characterized clinically by variable types of skin eruptions, including plaques, acneiform lesions, and alopecic patches. Histopathologically, FMF is characterized by folliculotropic infiltrates.

Objective

This study was conducted to scrutinize the clinical and histopathologic features of FMF in Koreans and the responses to phototherapy.

Methods

Twenty Koreans diagnosed with MF who had histopathologic evidence of folliculotropism were enrolled.

Results

Eighteen patients had head-and-neck-region infiltration, while five had solitary lesion. In all patients, the atypical lymphocytic infiltrate had a perifollicular distribution. Twelve patients were treated with ultraviolet A (UVA)-1. Eleven of these 12 patients with early-stage FMF experienced >80% improvement (8: complete remission; 3: partial remission). Four patients, including 2 who relapsed after UVA-1, were treated with photodynamic therapy (PDT), reaching complete remission after PDT.

Conclusion

As FMF has variable clinical presentations, skin biopsy is required to confirm the diagnosis. And both UVA-1 and methyl aminolevulinate-PDT are clinically effective in treatment of early-stage FMF.

The effect of phototherapy on progression to tumors in patients with patch and plaque stage of mycosis fungoides

BACKGROUND

Phototherapy has been a mainstay in the treatment of mycosis fungoides (MF). However, the recent findings of UV-induced p53 mutations in advanced MF suggest that phototherapy may contribute to disease progression.

OBJECTIVE

The objective of this study was to evaluate the effect of phototherapy on the time to tumor progression and overall survival in MF.

MATERIALS AND METHODS

Retrospective analysis of patients seen at the University of Pittsburgh Cutaneous Lymphoma Clinic from 1979 to 2016.

RESULTS

A total of 345 patients with MF were identified. 258 (74.8%) were diagnosed at stage IA or IB. 43 out of the 258 (16.6%) progressed to tumor stage. Before tumor development, 30 out of the 43 (69.8%) patients received phototherapy, and 13 (30.2%) did not. Patients who received phototherapy had a longer median time to tumor progression than those who did not: 3.5 years (interquartile range = 1.9-5.7) versus 1.2 years (0.2-2.3) (p = .001). Patients who received phototherapy also survived longer: 6.9 years (interquartile range = 4.3-9.5) versus 3.8 years (3.0-4.5) (p = .014).

LIMITATIONS

Limited information on specific phototherapy start dates, durations, and treatment protocols.

CONCLUSIONS

The therapeutic effects of phototherapy, with longer times to tumor progression and increased overall survival, appear to outweigh its potential adverse effects.

Prevention and Mitigation of Experimental Autoimmune Encephalomyelitis by Murine β-Defensins via Induction of Regulatory T Cells

The antimicrobial peptide murine β-defensin-14 (mBD14) was found to exert, in addition to its antimicrobial activity, the capacity to induce regulatory T cells as demonstrated in the model of contact hypersensitivity. Because it is induced by ultraviolet radiation, mBD14 may contribute to the antigen-specific immunosuppression by ultraviolet radiation. To prove whether this applies also for other immunologic models and because ultraviolet radiation appears to have beneficial effects on multiple sclerosis, we utilized the model of experimental autoimmune encephalomyelitis. Injection of mBD14 into mice before immunization with myelin oligodendrocyte glycoprotein caused amelioration of the disease with less central nervous system inflammation and decreased levels of proinflammatory cytokines and cytotoxic T cells. The beneficial effect was due to Foxp3(+) regulatory T cells because it was lost on in vivo depletion of regulatory T cells. mBD14, however, also acts in a therapeutic setting, because injection of mBD14 into mice with clinical features of experimental autoimmune encephalomyelitis reduced the clinical score significantly. Human β-defensin-3, the human orthologue of mBD14, induced in vitro regulatory T cell-specific markers in CD4(+)CD25(-) T cells, shifting these nonregulatory cells into a regulatory phenotype with suppressive features. Thus, defensins may represent candidates worth being further pursued for the therapy of multiple sclerosis.

Review of narrowband ultraviolet B radiation in vitiligo

Vitiligo is a common, acquired pigmentary disorder of unknown etiology with great impact on patient’s appearance and quality of life. It presents a therapeutic challenge to many dermatologists. Photochemotherapy using psoralen and ultraviolet A (UVA) therapy, topical and oral immunosuppresants, as well as cosmetic camouflage are also commonly employed with varying clinical efficacy. Phototherapy is a popular treatment option, which includes both of the generalized ultraviolet B (UVB) therapies, broadband UVB and narrowband UVB (NB-UVB). It has been used favorably, both alone as well as in combination with other agents like topical calcineurin inhibitors, vitamin-D analogs. Combination therapies are useful and may provide quicker regimentation and treat vitiligo with an additive mechanism of action than UVB phototherapy. Advances in technology may lead to the continuing use of UVB phototherapy as a treatment for vitiligo through the development of sophisticated devices and delivery systems as well as innovative application methods. These will provide increased therapeutic options for all vitiligo patients, particularly those with refractory disease. In this article, I have reviewed the available data pertaining to efficacy and safety issues for NB-UVB as monotherapy, its comparison with psoralen plus UVA and other modes of phototherapy, combination regimens that have been tried and future prospects of NB-UVB in vitiligo.

UVA1 Laser in the Treatment of Vitiligo

OBJECTIVE

The purpose of this article was to evaluate the clinical efficacy and safety of a monochromatic 355 nm ultraviolet (UVA) laser in the treatment of vitiligo.

BACKGROUND DATA

Broadband and narrow-band UV phototherapy has been proposed as an effective therapeutic option in vitiligo patients.

METHODS

Seventeen consecutive, unselected patients (7 men and 10 women) were enrolled in an open-label, prospective study and treated twice weekly for 8 weeks at a fixed dose of 80-140 J/cm(2). Follow-up was 12 weeks.

RESULTS

Clinical repigmentation was observed in 15/17 patients (88.23%), with limited side effects (mild post-treatment erythema and itching). Results were maintained during the 12 week phototherapy-free follow-up period.

CONCLUSIONS

the present report suggests that UVA1 laser could be an applicable therapeutic option in patients with vitiligo.

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

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

Ultraviolet phototherapy for cutaneous diseases: a concise review

Phototherapy is the use of non-ionizing radiation, primarily in the ultraviolet spectrum, to treat disease. In dermatology, ultraviolet (UV) phototherapy remains an established, lower cost, and often preferred option for many common skin conditions, despite the introduction of newer potent biologics. This article introduces a principal therapeutic modality in the treatment of psoriasis, atopic dermatitis (eczema), vitiligo, and morphea among other diseases where oral manifestations may be present, providing basic information about the use of UVA, UVB, and PUVA. Practical considerations and side effects of phototherapy are described. Phototherapy is an effective treatment for many illnesses and carries a relatively benign side-effect profile.

Effect of oral photochemotherapy (8-methoxypsoralen + UVA) on the electrophysiologic function of retina

CONTEXT

Since we had observed electroretinographic (ERG) abnormalities in some patients undergoing photochemotherapy with normal eye examination, we decided to investigate the effects of this therapy on retinal function.

OBJECTIVE

To investigate the effects of oral photochemotherapy (8-methoxypsoralen + Ultraviolet-A) on electrophysiologic function of retina.

MATERIALS AND METHODS

Patients with vitiligo, psoriasis or eczema were enrolled. Patients with any abnormal eye exam or a positive drug or family history for retinal disease were excluded. Baseline standard ERG was provided with the RETIport32 device. The second ERG was performed 6 months after the first and at least 1 week after the last photochemotherapy session (mean number of sessions: 45 ± 11). The outcome measures were changes in rod response, standard combined response, single-flash cone response, 30-Hz flicker (N1-P1) and oscillatory potentials amplitudes.

RESULTS

Forty patients were enrolled; 20 of them (mean age: 31.1 ± 12 years) completed the study. The mean rod response b-wave amplitude decreased from 88.9 ± 47.5 to 86.4 ± 36.6 and standard combined response b-wave amplitude decreased from 266.52 to 261.85 µV (p = 0.422 and p = 0.968, respectively) and the standard combined response a-wave amplitude increased from 155.4 ± 40.0 at baseline to 165.1 ± 48.4 in the follow-up ERG (p = 0.092). The mean single-flash cone response a-wave amplitude decreased insignificantly in the follow-up ERG trace (34.5 ± 13.7 and 29 ± 15.4, respectively, p = 0.242). The mean single-flash cone response b-wave amplitude showed an insignificant increase (p = 0.087). The amplitudes of 30-Hz flicker wave and oscillatory potentials did not change significantly in the follow-up ERG (p = 0.551 and p = 0.739, respectively).

CONCLUSION

Since no significant change in ERG traces was observed, oral photochemotherapy seems safe for retinal electrophysiologic function.

UVA irradiation of the eye modulates the contact hypersensitivity of the skin and intestines by affecting mast cells in mice

BACKGROUND

Ultraviolet A (UVA) irradiation before allergic sensitization induces immunosuppression, but the precise mechanism remained unclear. In this study, we examined the influence of UVA irradiation of the eye on contact hypersensitivity (CHS) and the role of mast cells in CHS.

METHODS

We used two types of haptens, fluorescein isothiocyanate (FITC: a Th2 type hapten) and 4-ethoxymethylene-2-phenyl-2-oxazolin-5-one (oxazolone: a Th1 type hapten). A 300 kJ/m(2) dose of UVA irradiation was delivered to the eyes. After UVA irradiation, we sensitized abdominal shaved skin and challenged the ear epidermis and colons of these mice with each hapten.

RESULTS

After UVA irradiation, the CHS of the skin and colon were not inhibited in the FITC-sensitized mice. However, in the oxazolone-sensitized mice, only the CHS of the skin was inhibited by UVA irradiation. The inflammation of the colon became more severe after UVA irradiation. In mast cell-deficient (W/Wv) mice sensitized to FITC, the CHS was weaker than that in WT mice. Moreover, the reduction of immunosuppression in ear swelling was seen for one of the two models they used.

CONCLUSIONS

These results suggest that the mast cells induced by UVA irradiation of the eye have different roles in the epidermis and colon and have different responses to different haptens.

Revisited the potential risks of carcinogenicity of phototherapy in patients with psoriasis

The article presents published data on the assessment of the risk of cancerogenicity of multiple courses of phototherapy methods such as PUVA therapy and UVB-311 in psoriatic patients. The authors analyzed the incidence of malignant skin neoplasms (squamous cell carcinoma, basal cell carcinoma, malignant skin melanoma) among psoriatic patients from different population groups taking into account the cumulative radiation doses and number of procedures.

Effects of narrow band UVB (311 nm) irradiation on epidermal cells

Ultraviolet radiation (UVR) is known to be one of the most important environmental hazards acting on the skin. It was revealed that chronic exposure to UVR accelerates skin aging, induces immunosuppression and may lead to the development of skin cancers. On the other hand, UVR has been shown to be effective in the treatment of numerous skin diseases and thus, various phototherapy modalities have been developed to date. Narrow-band ultraviolet B (NB-UVB) emitting a light with a peak around 311 nm has been demonstrated to be effective in the treatment of various skin disorders; currently it is one of the most commonly used phototherapy devices. Despite NB-UVB has been developed more than 30 years ago, the exact mechanism of its therapeutic action remains poorly understood. To date, most of NB-UVB effects were attributed to its influence on immune cells; however, nearly 90% of NB-UVB irradiation is absorbed by epidermis and keratinocytes seem to be important players in mediating NB-UVB biological activity. Here, we have reviewed the current data about the influence of NB-UVB on epidermal cells, with a special emphasis on cell proliferation and death.

Localized scleroderma: assessment of the therapeutic response to phototherapy

BACKGROUND

Scleroderma is a chronic autoimmune disease characterized by progressive connective tissue sclerosis and microcirculatory changes. Localized scleroderma is considered a limited disease. However, in some cases atrophic and deforming lesions may be observed that hinder the normal development. Literature reports indicate phototherapy as a therapeutic modality with favorable response in cutaneous forms of scleroderma.

OBJECTIVES

This study had the purpose of assessing the phototherapy treatment for localized scleroderma.

METHODS

Patients with localized scleroderma were selected for phototherapy treatment. They were classified according to the type of localized scleroderma and evolutive stage of the lesions. Clinical examination and skin ultrasound were used to demonstrate the results thus obtained.

RESULTS

Some clinical improvement was observed after an average of 10 phototherapeutic sessions. All skin lesions were softer at clinical palpation with scores reduction upon pre and post treatment comparison. The ultrasound showed that most of the assessed lesions presented a decrease in dermal thickness, and only five maintained their previous measure. Treatment response was similar regardless of the type of phototherapeutic treatment employed.

CONCLUSIONS

The proposed treatment was effective for all lesions, regardless of the phototherapeutic modality employed. The improvement was observed in all treated skin lesions and confirmed by clinical evaluation and skin ultrasound.

A review of monochromatic excimer light in vitiligo

Phototherapy is a mainstay of vitiligo treatment and has varying rates of efficacy. Narrowband ultraviolet (UV) B (NB-UVB) and UVA have been used for decades, but it is only recently that monochromatic excimer light (MEL) was developed for use in dermatology and adapted for the treatment of vitiligo. The specific 308-nm radiation wavelength is delivered in a targeted form by the xenon-chloride excimer laser and is also available in an incoherent form that is commonly referred to as the excimer lamp. MEL administered by both laser and lamp has shown efficacy superior to NB-UVB for the treatment of vitiligo and induces more changes at the cellular level than conventional UVB modalities. The excimer laser is effective in adults and children with vitiligo in all skin types as monotherapy or in combination with other established vitiligo therapeutics. Treatment regimens studied included excimer laser two to three times weekly for up to 36 weeks. Patients commonly achieved > 75% repigmentation. The laser has also been used in combination with topical corticosteroids, calcineurin inhibitors and vitamin D analogues, as well as surgery, thus further expanding treatment options for patients with vitiligo. The excimer lamp has been used for treatments one to three times a week for up to 24 weeks and was found to be equal to excimer laser in a head-to-head comparison. It has also been used in combination with topical corticosteroids and oral vitamin E. Both MEL modalities have a limited adverse side-effect profile. Long-term effects are yet to be determined; however, based on available data on UVB phototherapy as well as the properties of MEL devices, there is probably only a minimal increased malignancy risk.

Effects of phototherapy on cytokines' levels and white blood cells in term neonate with hyperbilirubinemia

Objective:

Phototherapy is the most common treatment used for severe jaundice. There is increasing evidence that phototherapy can directly affect the expression and function of cell surface receptors including adhesion molecules, cytokines, and growth factor receptors. The aim of this study is to investigate the effect of phototherapy use on the levels of interleukin (IL)-1α, IL-6, and tumor necrosis factor (TNF)-α as cytokine expressions from keratinocytes, and also white blood cell counts in the treatment of neonate with hyperbilirubinemia.

Materials and Methods:

We studied 32 term newborns with hyperbilirubinemia. Blood samples were obtained before and 72 h after phototherapy. Serum levels of IL-1α, IL-6, TNF-α, and WBC count were measured in the samples using appropriate methods.

Results:

Serum TNF-α at 72 h of exposure to phototherapy increased, while the levels of IL-1α and IL-6 at the same time were decreased. These changes were not statistically significant. WBC counts rose significantly with phototherapy.

Conclusion:

Phototherapy in term neonate does not affect cytokines’ levels, but can raise peripheral WBC count.

The antifungal effect of light emitting diode on Malassezia yeasts

BACKGROUND

Malassezia (M.) species are members of the normal part of the skin flora, but they might induce or be involved with various cutaneous diseases. Although the role of Malassezia in the pathogenesis of cutaneous diseases is not fully understood, recent studies have shown that decreased density of Malassezia led to improvement of these diseases.

OBJECTIVE

To identify the antifungal effect of light emitting diode (LED) against Malassezia, its antifungal mechanisms and the impact on the keratinocytes.

METHODS

LED with various wavelengths (370-630nm) on Malassezia furfur, Malassezia sympodialis and Malassezia globosa was irradiated according to dose and then the antifungal effects were thereafter assessed. After irradiating LED with 392.5±1nm of wavelength according to dose on Malassezia species, reactive oxygen species (ROS) and lipid hydroperoxide production assay were measured. In addition, cell viability and inflammatory cytokines (IL-1α, IL-1β, TNF-α, TGF-β, TLR-2 and COX-2) expressions in normal human epidermal keratinocytes (NHEKs) by LED irradiation were evaluated.

RESULTS

The growth of Malassezia species was dose-dependently suppressed by both LED with 380±2 and 392.5±1nm wavelengths. The increases of intracellular and extracellular ROS by LED irradiation with 392.5±1nm wavelengths were significantly observed compared to control group. The cell viability and cytokines in NHEKs were not significantly affected by LED irradiation under 5J/cm(2)in vitro.

CONCLUSION

LED irradiation with 380±2 and 392.5±1nm wavelengths proved to have antifungal effect against Malassezia species and no impact on NHEKs under 5J/cm(2). The findings suggest that LED might be an adjunctive therapeutic light tool against Malassezia yeasts related cutaneous diseases.

Advances in the treatment of moderate-to-severe plaque psoriasis

PURPOSE

Advances in the treatment of moderate-to-severe plaque psoriasis, including new biological agents and related drugs, are reviewed.

SUMMARY

Most patients with psoriasis have mild disease that can be treated with topical agents alone; however, over one third of patients have more-extensive disease, called moderate-to-severe plaque psoriasis. Although effective, traditional therapies, including methotrexate, cyclosporine, acitretin, and phototherapy, have serious adverse effects that limit both the initiation and duration of treatment, necessitating sequential treatment regimens. With the increasing knowledge of the immune nature of the disease, biological agents that target T lymphocytes, tumor necrosis factor (TNF)-α, interleukin (IL)-12, and IL-23 have been used successfully in moderate-to-severe psoriasis. Etanercept, adalimumab, and infliximab are also highly effective in the treatment of moderate-to-severe plaque psoriasis. Ustekinumab, a new agent that targets IL-12 and IL-23, was approved for marketing in 2009 and offers similar efficacy and safety profiles to the anti-TNF agents. While the rapid onset and apparent lack of long-term toxicity of biological agents make them major advances in the treatment of more severe forms of psoriasis, the lack of extensive experience with these agents in patients with psoriasis leaves several unresolved issues that must be addressed before their exact place in therapy can be determined.

CONCLUSION

With the development of biological therapies over the past 10 years, health care providers have a much broader choice of highly effective agents with which to treat patients suffering from moderate-to-severe plaque psoriasis. Though costly to use, biological agents offer considerable advantages over previously available systemic therapies.

Clinical efficacy of blue light full body irradiation as treatment option for severe atopic dermatitis

BACKGROUND

Therapy of atopic dermatitis (AD) relies on immunosuppression and/or UV irradiation. Here, we assessed clinical efficacy and histopathological alterations induced by blue light-treatment of AD within an observational, non-interventional study.

METHODOLOGY/PRINCIPAL FINDINGS

36 patients with severe, chronic AD resisting long term disease control with local corticosteroids were included. Treatment consisted of one cycle of 5 consecutive blue light-irradiations (28.9 J/cm(2)). Patients were instructed to ask for treatment upon disease exacerbation despite interval therapy with topical corticosteroids. The majority of patients noted first improvements after 2-3 cycles. The EASI score was improved by 41% and 54% after 3 and 6 months, respectively (p≤0.005, and p≤0.002). Significant improvement of pruritus, sleep and life quality was noted especially after 6 months. Also, frequency and intensity of disease exacerbations and the usage of topical corticosteroids was reduced. Finally, immunohistochemistry of skin biopsies obtained at baseline and after 5 and 15 days revealed that, unlike UV light, blue light-treatment did not induce Langerhans cell or T cell depletion from skin.

CONCLUSIONS/SIGNIFICANCE

Blue light-irradiation may represent a suitable treatment option for AD providing long term control of disease. Future studies with larger patient cohorts within a randomized, placebo-controlled clinical trial are required to confirm this observation.

In vivo UVA irradiation of mouse is more efficient in promoting pulmonary melanoma metastasis than in vitro

BACKGROUND

We have previously shown in vitro that UVA increases the adhesiveness of mouse B16-F1 melanoma cells to endothelium.We have also shown in vivo that UVA exposure of C57BL/6 mice, i.v. injected with B16-F1 cells, increases formation of pulmonary colonies of melanoma. The aim of the present animal study was to confirm the previously observed in vivo UVA effect and to determine whether in vitro UVA-exposure of melanoma cells, prior the i.v. injection, will have an enhancing effect on the pulmonary colonization capacity of melanoma cells. As a second aim, UVA-derived immunosuppression was determined.

METHODS

Mice were i.v. injected with B16-F1 cells into the tail vein and then immediately exposed to UVA. Alternatively, to study the effect of UVA-induced adhesiveness on the colonization capacity of B16-F1 melanoma, cells were in vitro exposed prior to i.v. injection. Fourteen days after injection, lungs were collected and the number of pulmonary nodules was determined under dissecting microscope. The UVA-derived immunosuppression was measured by standard contact hypersensitivity assay.

RESULTS AND DISCUSSION

Obtained results have confirmed that mice, i.v. injected with B16-F1 cells and thereafter exposed to UVA, developed 4-times more of melanoma colonies in lungs as compared with the UVA non-exposed group (p < 0.01). The in vitro exposure of melanoma cells prior to their injection into mice, led only to induction of 1.5-times more of pulmonary tumor nodules, being however a statistically non-significant change. The obtained results postulate that the UVA-induced changes in the adhesive properties of melanoma cells do not alone account for the 4-fold increase in the pulmonary tumor formation. Instead, it suggests that some systemic effect in a mouse might be responsible for the increased metastasis formation. Indeed, UVA was found to induce moderate systemic immunosuppression, which effect might contribute to the UVA-induced melanoma metastasis in mice lungs.

UVA1 radiation inhibits calcineurin through oxidative damage mediated by photosensitization

The protein phosphatase calcineurin has been gradually revealing itself as the central controller of our immune response, although it is involved in a wide array of signaling pathways related to cellular development and cell cycle progression. As such, calcineurin is an attractive, yet delicate, therapeutic target for the prevention of allograft rejection and treatment of several inflammatory skin conditions. However, calcineurin activity is not only sensitive to immunosuppressants such as cyclosporin A and tacrolimus, but also subject to modulation by reactive oxygen species. We have recently shown, both in vivo and in vitro, that UVA1 radiation suppresses calcineurin activity. In this paper, we present evidence that this activity loss is due to singlet oxygen and superoxide generated by photosensitization and show that a closely related phosphatase, PP2A, is not affected. Furthermore, a survey of this damage reveals oxidation of several Met and Cys residues as well as an overall conformational change. These findings provide a mechanistic basis for the hypothesis that UVA1 and calcineurin inhibitors both affect the same signal transduction pathway in skin.

Cutaneous T-cell lymphoma: Biologic targets for therapy

Cutaneous T-cell lymphoma (CTCL) is a malignancy derived from a clonal population of mature, skin-homing lymphocytes. In the skin, the CTCL cells are associated with the Langerhans cells and respond to protumor cytokines. In turn, they upregulate T-cell receptor-dependent signaling pathways and subsequently demonstrate stigmata of T-cell activation. As the disease progresses, there appears to be an accumulation of genetic and epigenetic changes that may contribute to the aggressiveness of the disease. Furthermore, the persistence of tumor appears to require escape from cancer immunosurveillance. This process likely requires modulation of the host immune system and skewing of the immune cells away from a cytotoxic phenotype. Each of these steps in disease pathogenesis offers a potential object for targeted therapies. This article reviews the recent research into the design and use of targeted therapies for CTCL.

Development of nitrosyl ruthenium complex-loaded lipid carriers for topical administration: improvement in skin stability and in nitric oxide release by visible light irradiation

The prominent nitric oxide (NO) donor [Ru(terpy)(bdqi)NO](PF(6))(3) has been synthesized and evaluated with respect to noteworthy biological effects due to its NO photorelease, including vascular relaxation and melanoma cell culture toxicity. The potential for delivering NO in therapeutic quantities is tenable since the nitrosyl ruthenium complex (NRC) must first reach the "target tissue" and then release the NO upon stimulus. In this context, NRC-loaded lipid carriers were developed and characterized to further explore its topical administration for applications such as skin cancer treatment. NRC-loaded solid lipid nanoparticles (SLN) and nanostructured lipid carriers were prepared via the microemulsification method, with average diameters of 275+/-15 nm and 211+/-31 nm and zeta potentials of -40.7+/-10.4 mV and -50.0+/-7.5 mV, respectively. In vitro kinetic studies of NRC release from nanoparticles showed sustained release of NRC from the lipid carriers and illustrated the influence of the release medium and the lyophilization process. Stability studies showed that NO is released from NRC as a function of temperature and time and due to skin contact. The encapsulation of NRC in SLN followed by its lyophilization, significantly improved the complex stability. Furthermore, of particular interest was the fact that in the NO photorelease study, the NO release from the NRC-loaded SLN was approximately twice that of just NRC in solution. NRC-loaded SLN performs well enough at releasing and protecting NO degradation in vitro that it is a promising carrier for topical delivery of NO.

Currentaspects of psoriasis phototherapy

The review covers current aspects of ultraviolet therapy for patients suffering from psoriasis. It describes mechanisms of action as well as early and remote side effects of the current phototherapy methods. The review also presents data from literature about the risk of their cancerogenicity. It also discusses approaches to the optimization of phototherapy in view of risks and benefits for the patient.