Comparison of 8-MOP aqueous bath and 8-MOP ethanolic lotion (Meladinine) in local PUVA therapy

Psoralen plus ultraviolet A (PUVA) soaks and UVB TL01 treatment for chronic hand dermatoses

Chronic eczematous hand dermatoses with and without contact allergies are complex diseases, which makes it a challenge to select the best treatment and obtain an optimal patient experience and a satisfactory treatment result. The aim of this study was to evaluate retrospectively the clinical effect and patient experience of local treatment with psoralen plus ultraviolet A (PUVA) soaks and TL01 phototherapy for severe chronic hand dermatoses, and also to evaluate the quality of life for the subgroup of patients with allergic contact dermatitis including Compositae allergy. A retrospective evaluation of results for 94 consecutive patients having received a total of 121 treatment courses with local PUVA soaks or TL01 phototherapy for one of the following diagnoses (n=number of treatment courses): psoriasis (n=19), hyperk-eratotic hand eczema (n=27), Pustulosis Palmoplantaris (PPP) (n=22), vesicular eczema (n=16), Compositae dermatitis (n=24), and allergic contact dermatitis (n=13). Moreover, semi-structured interviews with 6 selected patients having multiple contact allergies including Compositae allergy were used to evaluate quality of life. As a result, we found that PUVA soaks has good effect in patients with psoriasis and hyperkeratotic hand eczema and local phototherapy for chronic hand dermatoses is a useful treatment option in selected cases.

The use of topical PUVA for palmoplantar dermatoses

Palmoplantar dermatoses have a tendency to be chronic and are frequently recalcitrant to treatment. We summarize our experience with paint PUVA in the treatment of 125 patients with palmoplantar dermatoses between the years 1996 and 2000. The dominant clinical picture of the lesions was hyperkeratosis in 84, pustulosis in 11 and exudative dermatitis in the remaining 30 patients. The treatment was applied thrice weekly on alternate days. The affected skin was painted with methoxsalen 0.1% solution, and exposed 30 minutes later to UVA radiation, starting at 0.25 J/cm(2), with increments of 0.25-0.50 J/cm(2) every third treatment. Complete response was considered if all signs disappeared, and partial response if improvement occurred in more than 75% of each of the clinical findings of scaling erythema, fissuring, pustule formation and infiltration. Sixty-nine percent of the patients had a good response (i.e. a complete or partial response), which was achieved in 78.5% of the exudative dermatitis lesions, but in only 46.7% of the pustular lesions. The average time to achieve good response was 13 weeks (range 1-42), with an average total dose of 50 J/cm(2) (range 0.50-366). Maintenance therapy every 1-4 weeks was recommended for all responding patients, but only 58 consented and were treated for an average period of 10 additional weeks. Side effects were minor and transient, mainly mild first-degree superficial skin burns in 10 patients, and patchy hyperpigmentation in three patients, which resolved after a few weeks.

Comparison of the efficacy of local narrowband ultraviolet B (NB-UVB) phototherapy versus psoralen plus ultraviolet A (PUVA) paint for palmoplantar psoriasis

Palmoplantar psoriasis is an idiopathic disabling condition, often resistant to conventional therapies. The purpose of this study was to evaluate the efficacy and safety of local narrowband ultraviolet B (NB-UVB) phototherapy and to compare it with local psoralen plus ultraviolet A (PUVA) paint in patients with palmoplantar psoriasis unresponsive to conventional therapies other than phototherapy. A cohort of 25 patients with palmoplantar psoriasis were included in this study, which was based on a left-to-right comparison pattern. The treatments were administered with local narrowband UVB irradiation on one side and local PUVA on the other side three times a week over 9 weeks. Clinical assessments were performed at baseline and every 3 weeks during the 9-week treatment. There was a statistically significant decrease in the mean clinical scores at the third, sixth and ninth week with both treatments. The difference in clinical response between the two treatment modalities was statistically significant at the end of the treatment period, with the percentage reduction in severity index scores with the PUVA-paint-treated side being 85.45% compared with 61.08% for the NB-UVB treated side (t = 5.379, P = 0.0001, Student's t-test for unpaired samples). Our results show that, although some clinical improvement was achieved with local NB-UVB phototherapy, the results were better with local PUVA, and such a treatment option may be reserved for patients with palmoplantar psoriasis who experience phototoxic reaction to psoralens.

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

BACKGROUND

Hand eczema is a chronic skin disorder characterized by a poor response to conventional therapies. Although local PUVA has been proven to be effective in the treatment of chronic hand eczema, little is known about the efficacy and safety of local narrowband UVB (TL-01) for this condition. The aim of our study was to compare the efficacy and safety of local narrowband UVB phototherapy with paint-PUVA in patients with chronic hand eczema of dry and dyshidrotic types unresponsive to conventional therapies.

PATIENTS/METHODS

Fifteen patients (nine men and six women) with chronic hand eczema of dry and dyshidrotic types was included in this prospective, comparative study based on a left to right comparison pattern. The treatments were administered with local narrowband UVB irradiation on one hand and local paint-PUVA using 0.1% 8-methoxypsoralen gel on the other hand three times a week over a 9-week period. The NB-UVB irradiation was administered using a local NB-UVB system equipped with TL-01 lamps. The initial dose was 150 mJ/cm(2) for each patient. An increasing percentile dose schedule based on an increase of 20% was used in every session, until a final dose of 2000 mJ/cm(2) was reached. Evaluation of clinical scores was carried out every 3 weeks during the treatment period.

RESULTS

Twelve of the 15 recruited patients completed the study. There was a statistically significant decrease in the mean clinical score at the third, sixth and nineth week in both groups. The difference in clinical response between the two treatment modalities was not statistically significant at the end of the 9-week treatment period. In the narrowband UVB-treated side, the tolerance of all the patients to the treatment was good all patients well-tolerated the treatment with the exception of mild xerosis that responded to topical emollients.

CONCLUSION

Local narrowband UVB phototherapy regimen is as effective as paint-PUVA therapy in patients with chronic hand eczema of dry and dyshidrotic types.

Interventions for chronic palmoplantar pustulosis

BACKGROUND

Chronic palmoplantar pustulosis (PPP) is a chronic inflammatory skin condition characterised by crops of sterile pustules (yellow pus spots) on the palms and soles which erupt repeatedly over months or years. The affected areas tend to become red and scaly; cracks may form and these are often painful. Many different treatments have been used for palmoplantar pustulosis but none is generally accepted as being reliably effective.

OBJECTIVES

To assess the effects of treatments for palmoplantar pustulosis, both in reducing disease severity and in maintaining remission once achieved.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (January 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to February 2003). We also cross-checked with the Salford Database of Psoriasis Trials and reference lists of articles. We also contacted authors included trials, members of the Cochrane Skin Group and dermatologists interested in psoriasis.

SELECTION CRITERIA

Any randomised controlled trial in which patients with chronic palmoplantar pustulosis were randomised to receive one or more interventions.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed trial eligibility and quality. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Twenty-three trials involving 724 people were included. There is evidence supporting the use of systemic retinoids (improvement rate difference 44%, 95 CI 28 to 59%), oral PUVA (improvement rate difference 44%, 95 CI 26 to 62%). However, a combination of PUVA and retinoids is better than the individual treatments. The use of topical steroid under hydrocolloid occlusion is beneficial. It would also appear that low dose ciclosporin, tetracycline antibiotics and Grenz Ray Therapy may be useful in treating PPP. Colchicine has a lot of side effects and it is unclear if it is effective and neither was topical PUVA (rate difference of 0.00, 95% CI -0.04 to +0.04). There is no evidence to suggest that short-term treatment with hydroxycarbamide (hydroxyurea) is effective.

AUTHORS' CONCLUSIONS

Many different interventions were reported to produce "improvement" in PPP. There is, however, no standardised method for assessing response to treatment, and reductions in pustule counts or other empirical semi-quantitative scoring systems may be of little relevance to the patient. This review has shown that the ideal treatment for PPP remains elusive and that the standards of study design and reporting need to be improved to inform patients and those treating them of the relative merits of the many treatments available to them.

PUVA-gel vs. PUVA-bath therapy for severe recalcitrant palmoplantar dermatoses. A randomized, single-blinded prospective study

BACKGROUND/PURPOSE

In order to avoid unwanted effects of systemic psoralen and ultraviolet A (PUVA) therapy, various topical PUVA treatment modalities have been developed and are being increasingly used. However, up to now very few controlled studies comparing the therapeutic efficacy of different topical photochemotherapy modalities are available. Thus, the aim of our study was to compare the clinical efficacy of conventional PUVA-bath therapy to topical PUVA-gel therapy in patients with recalcitrant dermatoses of the palms and soles.

METHODS

Twenty patients with severe palmoplantar dermatoses or localized psoriatic plaques were enrolled in our observer-blinded, randomized half-sided study. The treatment modalities compared were: (i) aqueous 8-methoxypsoralen (8-MOP)-containing gel plus broadband UVA irradiation (PUVA-gel therapy) and (ii) 8-MOP bath of the hands and/or feet plus broadband UVA (PUVA-bath therapy).

RESULTS

On the body half, which was randomized to PUVA-gel therapy, the median Area and Severity Index for palmoplantar dermatoses (ASIppd) decreased from 28 (range 6-56) to 1.5 (range 1-37, P = 0.00) after a median 33 (13-49) irradiations compared with a reduction from 26.5 (range 6-52.5) to 1.5 (range 0-38, P = 0.00) for PUVA-bath therapy. Both improvements of ASIppd scores were found to be statistically significant, with no significant difference between PUVA-gel and PUVA-bath therapy. Severe phototoxic reactions such as strong erythema, blistering and/or pain were not observed in any patient.

CONCLUSION

PUVA-gel therapy seems to be an effective therapeutic alternative to conventional PUVA-bath therapy in treating localized dermatoses of the palms and soles. The advantage of PUVA-gel therapy is reduced organizational efforts and expenses.

Hand and foot PUVA soaks: an audit of the Massachusetts General Hospital's experience from 1994 to 1998

Palmoplantar psoriasis and eczema can be chronic recalcitrant dermatoses. Oral psoralen plus ultraviolet A (PUVA) has proven effective for these, but has a number of unwanted side effects. Previous studies have shown that regional PUVA therapy using the 8-methoxypsoralen (8-MOP) soak method followed by immediate UVA irradiation is also beneficial and well tolerated. The purpose of this audit was to determine the efficacy of hand and foot PUVA soaks by reviewing the experience of the Massachusetts General Hospital's Phototherapy Unit with this treatment modality. Phototherapy records of all patients who underwent hand and foot PUVA soaks from 1994 to 1998 were reviewed. Details regarding the treatment procedure, patient compliance, patient response and incidence of side effects were noted and summarized. Of the 56 patients who underwent at least 20 treatments, 29% had excellent response, 42% had minimal to moderate response, and 29% had poor response. The average number of treatments to induce clearing was 41. The average maximum treatment dose at clearing was 5.85 J/cm2, while the average cumulative dose to achieve clearing was 267.17 J/cm2. 8-MOP PUVA soak therapy is quite useful for chronic hand and foot dermatoses. Patient compliance must be emphasized to obtain favorable results.