Efficacy of ultraviolet A1 phototherapy in recalcitrant skin diseases

Clinical, histopathological and immunohistochemical evaluation of ultraviolet A1 treatment in early-stage mycosis fungoides

BACKGROUND/PURPOSE

Mycosis fungoides (MF) is the most common variant of cutaneous T-cell lymphomas primarily involving the skin. Early-stage MF is characterised by non-specific skin lesions and non-diagnostic biopsies. While skin-focused treatments, such as PUVA and narrowband UVB (nbUVB), are the most frequently recommended treatments, the UVA1 efficacy has been researched in recent years. The purpose of this study was to evaluate the clinical, histopathological and immunohistochemical aspects of UVA1 treatment in patients with early-stage MF.

METHODS

The modified severity weighted assessment scale (mSWAT) was used for total skin body scoring before and after treatment. Skin punch biopsies were taken from the patients before and after treatment. UVA1 therapy was performed five times each week.

RESULTS

This study included 26 patients with early-stage MF. The total number of UVA1 sessions varied between 15 and 34. Complete response was observed in 8 (30.8%) of 26 patients (30.8%). The median mSWAT score decreased statistically significantly from 7.1 to 2.0 after treatment (p < .001). Histopathological complete response was observed in 2 (9.5%) of 21 patients. A statistically significant decrease in dermal interstitial infiltrate was observed on histopathological examination after treatment (p = .039). Epidermal CD4/CD8 levels decreased statistically significantly higher from a median of 2.5-1.2 in the complete clinical response group after treatment (p = .043).

CONCLUSION

According to our results, UVA1 treatment has an effect on early-stage MF in terms of clinical, histopathological and immunohistochemistry.

Utilizing UVA-1 Phototherapy

There is a long history of utilization of phototherapy for treatment of skin conditions. Because of its longer wavelength, UVA1 phototherapy is able to penetrate into the dermis and subcutis. This depth of penetration, combined with its unique immunomodulating properties, makes UVA1 an effective treatment modality for many immune-mediated skin diseases. In some cases, it performs better than other types of phototherapy.

A retrospective review of UVA1 treatment: An Australian experience from a single centre

BACKGROUND

The therapeutic value of ultraviolet A1 (UVA1) phototherapy has been acknowledged for many years. Initially developed predominately for experimental and diagnostic purposes, it was subsequently recognised as a beneficial therapeutic modality in atopic dermatitis and localised scleroderma, and more recently a variety of sclerosing and fibrosing dermatoses, T-lymphocyte mediated disorders, both inflammatory and infiltrative, and several predominately dermal processes previously unresponsive to current therapies.

METHODS

We present a retrospective evaluation of outcomes and treatment tolerability in adult patients using a low dose (30 joules/cm² ), regimen administered in our private dermatologic practice, between 2006 and December 2019.

RESULTS

Major clinical groups represented include atopic dermatitis, localised and systemic sclerodermas, mycosis fungoides, urticarial dermatitis, generalised pruritus and granuloma annulare. Eighty-seven patients are included in this study with 92% of all patients experiencing a beneficial result, 54% having complete and 38% partial relief of presenting signs and/or symptoms. UVA1 therapy was well tolerated, with no patients ceasing treatment due to adverse effects.

CONCLUSIONS

Ultraviolet A1 is an effective and safe treatment option in many hitherto recalcitrant cutaneous conditions.

The effectiveness of high-dose ultraviolet A-1 phototherapy for acute exacerbation of atopic dermatitis in Asians

BACKGROUND/PURPOSE

Atopic dermatitis (AD) is an inflammatory skin disease characterized by a chronic course of exacerbations and remissions. High-dose ultraviolet A-1 (UVA-1) phototherapy has been effective in the treatment of acute exacerbations of AD. However, there have been no case studies in Asian patients to date. We investigated the effectiveness of high-dose UVA-1 phototherapy for treating acute exacerbation of AD in Asian patients.

METHOD

This study included 16 patients with acute exacerbation of AD. High-dose (100 J/cm² ) regimens of UVA-1 therapy were employed. Therapeutic effectiveness was assessed based on the findings of clinical examinations and scoring of AD (SCORAD) index before treatment and after the 5th and 10th sessions of treatment. Additionally, side effects and recurrence during follow-up were retrospectively evaluated.

RESULTS

The patients were between 7 and 50 years of age, with a mean age of 25.8 years. The SCORAD index was between 41 and 89.5, with a mean score of 64.9. Among the 16 patients, two patients discontinued treatment due to the aggravation of erythema and pruritus. Of the 14 patients who completed the 10 sessions of high-dose UVA-1 phototherapy, nine patients (64.3%) showed complete remission and five patients (35.7%) showed partial remission. The mean SCORAD index reduced from 64.9 (before treatment) to 23.3 (after the 10th session of treatment).

CONCLUSION

This is the first case study of high-dose UVA-1 phototherapy for acute exacerbation of AD in Asian patients, suggesting that high-dose UVA-1 phototherapy can be a well-tolerated and effective treatment for acute exacerbated AD. Future large-scale prospective studies are needed.

Ultraviolet A1 Phototherapy for Fibrosing Conditions

In this article we describe efficacy and safety aspects of ultraviolet A1 (UV-A1) phototherapy in fibrosing conditions. UV-A1 is a specific phototherapeutic modality that is defined by a selective spectral range (340–400 nm). UV-A1 includes distinct modes of action qualifying this method for therapy of a variety of conditions, in particular fibrosing skin diseases. Concerning efficacy of UV-A1 phototherapy in fibrosing conditions, the best evidence obtained from randomized controlled trials exists for localized scleroderma. Moreover, fibrosing disorders such as lichen sclerosus and graft-vs.-host disease can be treated successfully by means of UV- A1. Regarding the optimal dosage regimen medium-dose UV-A1 seems to be linked to the best benefit/risk ratio. Possible acute adverse events of UV-A1 phototherapy include erythema and provocation of photodermatoses. Skin ageing and skin cancer formation belong to the chronic adverse events that may occur after long-term UV-A1 phototherapy.

Pityriasis Lichenoides-like Mycosis Fungoides: Clinical and Histologic Features and Response to Phototherapy

Background

Pityriasis lichenoides (PL)-like skin lesions rarely appear as a specific manifestation of mycosis fungoides (MF).

Objective

We investigated the clinicopathological features, immunophenotypes, and treatments of PL-like MF.

Methods

This study included 15 patients with PL-like lesions selected from a population of 316 patients diagnosed with MF at one institution.

Results

The patients were between 4 and 59 years of age. Four patients were older than 20 years of age. All of the patients had early-stage MF. In all patients, the atypical lymphocytic infiltrate had a perivascular distribution with epidermotropism. The CD4/CD8 ratio was <1 in 12 patients. Thirteen patients were treated with either narrowband ultraviolet B (NBUVB) or psoralen+ultraviolet A (PUVA), and all of them had complete responses.

Conclusion

PL-like MF appears to have a favorable prognosis and occurrence of this variant in adults is uncommon. MF should be suspected in the case of a PL-like skin eruption. Therefore, biopsy is required to confirm the diagnosis of PL-like MF, and NBUVB is a clinically effective treatment.

Phototherapy in Scleroderma

Systemic and localized scleroderma are difficult to manage diseases with no accepted gold standard of therapy to date. Phototherapeutic modalities for scleroderma show promise. A PubMed search of information on phototherapy for scleroderma was conducted. The information was classified into effects on pathogenesis and clinical outcomes. Studies on photopheresis were excluded. There were no randomized, double-blind, placebo-controlled studies, and only three controlled studies. The vast majority of identified studies evaluated ultraviolet A1 (UVA1) phototherapy. More rigorous studies are needed to evaluate phototherapy in the treatment of scleroderma. Based on the limited studies available, 20-50 J/cm² of UVA1 therapy 3-4 times a week for 30 treatments is recommended.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part II): Systemic Treatment

BACKGROUND

Since the treatment guidelines for atopic dermatitis (AD) were issued by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been further advances in the systemic treatment of AD.

OBJECTIVE

We aimed to establish updated evidence- and experience-based systemic treatment guidelines for Korean AD.

METHODS

We compiled a database of references from relevant systematic reviews and guidelines regarding the systemic management of AD, including antihistamines, antimicrobials, systemic immunomodulators, allergen-specific immunotherapy, phototherapy, adjunctive treatment, and complementary and alternative medicines. Evidence for each statement was graded and classified based on the strength of the recommendation. Thirty-nine council members of KADA participated in the three rounds of votes and expert consensus recommendations were established.

RESULTS

The use of antihistamines is recommended to relieve pruritus and to prevent exacerbation due to scratching in AD patients. Infection should be controlled as needed and long-term medication should be avoided. For moderate to severe AD patients, concomitant active treatments with systemic immunomodulators are indicated. Cyclosporine is the first choice among systemic immunomodulators and others should be considered as second-line alternatives. Allergen-specific immunotherapy could be effective in AD patients with aeroallergen hypersensitivity. Phototherapy can be useful for moderate to severe AD patients and narrow-band ultraviolet B is the most effective option. Complementary and alternative medicines cannot be recommended for treating AD.

CONCLUSION

We expect these recommendations to be a reference guide for physicians and AD patients in choosing the appropriate treatment to improve quality of life and decrease unnecessary social medical costs.

Pediatric mycosis fungoides in Singapore: a series of 46 children

Few studies have evaluated Asian children with mycosis fungoides (MF). We report a series of patients from a tertiary dermatologic institution in Singapore. A retrospective review was performed of patients younger than 16 years old diagnosed with MF between 2000 and 2008 at the National Skin Centre, Singapore. Forty-six patients were identified. At initial presentation, a provisional diagnosis of MF was made in 19 patients (41.3%), pityriasis lichenoides chronica (PLC) in 11 (23.9%) and postinflammatory hypopigmentation due to eczema or other causes in 11 (23.9%). After skin biopsy, the hypopigmented variant of MF was diagnosed in 42 patients (91.3%). There was one case each of PLC-like MF, pigmented purpuric dermatosis-like MF, classic MF, and solitary MF. Pityriasis lichenoides coexisted in three cases (6.5%). All except one patient presented with the early patch-plaque stage of disease (stage IA/B). The disease did not progress in any of our patients after a mean follow-up of 71.0 ± 52.5 months. Twenty-seven patients (58.7%) had complete disease clearance after a mean duration of 27.1 ± 28.1 months; 15 (49.7%) of 32 patients who received narrowband ultraviolet B treatment had complete clearance within an average of 8.9 ± 5.3 months, but 7 patients relapsed within 14.9 ± 14.8 months. One patient with solitary MF failed multiple treatment modalities before eventually achieving disease clearance with photodynamic therapy. Hypopigmented MF is the most common MF variant in Asian children. The diagnostic difficulty is in differentiating this from PLC, which may coexist with MF. Long-term prognosis is generally favorable.

Efficacy of low-dose ultraviolet a-1 phototherapy for parapsoriasis/early-stage mycosis fungoides

Mycosis fungoides (MF) and parapsoriasis (PP) are major dermatologic conditions for which phototherapy continues to be a successful and valuable treatment option. UVA-1 phototherapy is effective in the management of cutaneous T-cell mediated diseases. The aim of the study was to evaluate the efficacy and safety of low-dose UVA-1 phototherapy for the management of PP/early-stage MF. A total of 30 patients, diagnosed with MF (n:19) or PP (n:11) were enrolled to the study. All patients were managed with low-dose UVA-1 (20 or 30 J cm(-2)). Response was assessed clinically and immunohistochemically. UVA-1 treatment led to clinical and histological complete remission (CR) in 11 of 19 MF patients (57.9%), partial remission (PR) in three of 19 (15.8%), after a mean cumulative dose of 1665 (range, 860-3120) J cm(-2) and mean number of 73 exposure (range, 43-107) sessions. Five patients with PP (45.5%) showed CR, and PR was observed in six patients with PP (54.5%) after a mean cumulative dose of 1723 (range, 1060-3030) J cm(-2) and mean number of 74 exposure (range, 53-101) sessions. We conclude that low-dose UVA-1 therapy seems to be an effective, safe, and well-tolerated treatment option for patients with PP/early-stage MF.

Atopic dermatitis: a practice parameter update 2012

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Atopic dermatitis: a practice parameter update 2012." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. Published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available online at http://www.jcaai.org.

UVA1 irradiation inhibits fibroblast proliferation and alleviates pathological changes of scleroderma in a mouse model

The purpose of the present study was to compare the effects of different doses of ultraviolet radiation A1 (UVA1) on human fibroblast proliferation and collagen level in a mouse model of scleroderma, so as to identify appropriate irradiation doses for clinical treatment of scleroderma. Monolayer from human fibroblasts was cultured in vitro, and a mouse model of scleroderma was established by subcutaneous injection of 100 µL of 400 µg/mL bleomycin into the back of BALB/c mice for 4 weeks. The mouse models and human fibroblasts were divided into UVA1-exposed (100, 60 and 20 J/cm²) and UVA-unexposed groups. At 0, 24 and 48 h after exposure, cell proliferation and levels of hydroxyproline and collagen were detected. UVA1 irradiation was performed 3 times weekly for 10 weeks, and the pathological changes of skin tissues, skin thickness and collagen level were observed after phototherapy. Cell proliferation and the levels of hydroxyproline and collagen were inhibited after phototherapy, and there was a significant difference between the UVA1-exposed cells and UVA1-unexposed cells (P < 0.001). In addition, UVA1 phototherapy improved dermal sclerosis and softened the skin, and there were significant differences between the high-dose UVA1 group and the model group, and the negative group (P < 0.05). It is concluded that UVA1 radiation can reduce cell proliferation, and decrease hydroxyproline and collagen levels in a dose-dependent manner in vitro. High-dose UVA1 phototherapy has marked therapeutic effect on scleroderma in the mouse model. Decreased collagen level may be related to the reduced number and activity of cells, as well as inhibition of collagen synthesis.

Ultraviolet A1 phototherapy for mycosis fungoides

BACKGROUND

Mycosis fungoides (MF) is the most common form of primary cutaneous lymphoma, and is characterized by a malignant proliferation of CD4+ cells. Psoralen ultraviolet A (PUVA) irradiation is the most common treatment for cutaneous lesions. However, PUVA carries the risk of adverse reactions to psoralens and long-term risk of skin cancer. UVA1 may be a safer alternative.

AIM

To assess the efficacy of UVA1 phototherapy in patients with early-stage MF (T1-T2).

METHODS

Four patients with early-stage MF were treated with 1630-2710 J/cm(2) UVA1 given in 29-40 fractions, and the effect was assessed by clinical examination and by high-resolution ultrasonography.

RESULTS

Complete clinical remission of MF was achieved in all cases.

CONCLUSIONS

This preliminary report indicates that UVA1 phototherapy might be an efficient treatment for early-stage MF.

Modern aspects of phototherapy for atopic dermatitis

Phototherapy has still great importance in the treatment of atopic dermatitis, though costs, compliance, and long-term risks narrow its relevance. In spite of its long history, up to now, the therapeutic regimes are mostly empirical. Narrowband UVB und UVA1 are the most frequently applied regimens in atopic dermatitis with proven efficacy. However, even for these modalities randomized prospective and controlled studies are still pending. Advances in photoimmunology and molecular biology had demonstrated that phototherapy targets inflammatory cells, alters cytokine production, and has a significant antimicrobial effect within atopic skin. This paper summarizes the current literature on the different regimes of phototherapy and also discusses therapeutic modalities like photochemotherapy and extracorporeal photopheresis. These more complex regimes should be restricted to severe cases of atopic dermatitis, which are refractory to topical treatment.