Clinical course of psoriasis patients that discontinued biologics during the COVID-19 pandemic

BACKGROUND

Since psoriasis is a chronic disease, it is not recommended to discontinue the treatment agents used. However, in real life, the treatment of psoriasis patients may be interrupted for various reasons. During the pandemic period, the treatment of many patients was also interrupted.

OBJECTIVES

To evaluate relapse and clinical worsening in psoriasis patients whose biological therapy was interrupted during the pandemic and reveal associated factors.

METHODS

The study included patients aged ≥18 years, who were followed up with moderate and severe chronic psoriasis controlled by the last biological agent [Psoriasis Area Severity Index (PASI) 75 response achieved] but had to discontinue their treatment during the pandemic. The patients' demographic and clinical characteristics, clinical course after the discontinuation of these agents, presence of clinical worsening, and relapse were evaluated. Risk factors were analyzed with the logistic regression analysis.

RESULTS

The study included 169 patients, with a mean age of 47.3 ± 14.5 (18-87) years. The mean biologics-free time was 18.2 ± 12.3 (2-56) weeks. Clinical worsening was detected in 41.4% and relapse in 48.5% of the patients. The significant risk factors for clinical worsening and relapse in both univariate and multivariate analyses were alcohol use during the biologics-free period, total time off biologics, and the presence of an additional triggering factor. The use of secukinumab and ustekinumab was found to be a protective factor against clinical worsening in multivariate analyses.

CONCLUSION

As the biologics-free period is prolonged, the likelihood of clinical worsening and relapse increases, therefore, we do not recommend discontinuing biological agents.

Skin manifestations following anti-COVID-19 vaccination: A multicentricstudy from Turkey

PURPOSE

After the emergence of the pandemic caused by the COVID-19 virus, vaccination with various vaccines has started to be implemented across the world. To identify dermatological reactions developing after the COVID-19 vaccines administered in Turkey and determine their clinical features and risk factors that may play a role in their development.

MATERIALS AND METHODS

The study included patients aged ≥18 years, who presented to 13 different dermatology clinics in Turkey between July 2021 and September 2021 after developing dermatological reactions following the administration of the COVID-19 vaccine. After providing written consent, the patients were asked to complete a standard survey including questions related to age, gender, occupation, comorbidities, the regular medication used, the onset of cutaneous reactions after vaccination, and localization of reactions. Dermatological reactions were categorized according to whether they developed after the first or second dose of the vaccine or whether they occurred after the inactivated or messenger RNA (mRNA) vaccine. The relationship between dermatological reactions and some variables such as gender and comorbidities was also evaluated.

RESULTS

A total of 269 patients [116 women (43.1%), 153 men (56.9%)] were included in the study. It was observed that the dermatological diseases and reactions that most frequently developed after vaccination were urticaria (25.7%), herpes zoster (24.9%), maculopapular eruption (12.3%), and pityriasis rosea (4.5%). The rate of dermatological reactions was 60.6% after the administration of the mRNA vaccine and 39.4% after that of the inactivated vaccine. There was a statistically significantly higher number of reactions among the patients that received the mRNA vaccine (p = 0.001).

CONCLUSION

The most common reactions in our sample were urticaria, herpes zoster, and maculopapular eruption. Physicians should know the dermatological side effects of COVID-19 vaccines and their clinical features.

Patient Use of Complementary and Alternative Medicine for Psoriasis Vulgaris and Factors Believed to Trigger the Disease: a Multicenter Cross-Sectional Study With 1621 Patients

INTRODUCTION

Due to the chronic recurrent nature of psoriasis vulgaris (PV) and lack of definitive treatment for the disease, patients often resort to alternative treatments. Physicians seem to have low awareness of this issue.

OBJECTIVES

To elicit the perceptions of 1,621 PV patients on complementary and alternative medicine (CAM) and examine factors reported to worsen PV.

METHODS

The patients sociodemographic characteristics, Psoriasis Area Severity Index (PASI), Dermatology Life Quality Index (DLQI), disease duration, and severity were recorded, and the patients CAM use was questioned in detail. The patients were also asked about factors that worsened PV and their experiences with a gluten-free diet.

RESULTS

Of the patients, 56.51% had used CAM. The mean age, illness duration, PASI scores and DLQI of those using CAM were significantly higher. CAM use was significantly higher in those with facial, genital involvement, and arthralgia/arthritis. The patients mostly referred to CAM when PV became severe (46.4%). Of the CAM users, 45.52% used herbal topicals. The physicians of 67.03% did not inquire whether they used CAM. Of the participants, 37.73% considered that stress worsened their disease. Gluten-free diet did not affect PV symptoms in 52.22%.

CONCLUSIONS

Patients CAM use is often overlooked by dermatologists. Our results showed that more than half the patients used CAM and did not share this information with their physicians. Therefore, the awareness of physicians should be increased and patients should be asked about the use of CAM and directed to the appropriate medical treatment options by physicians.

Habits of using social media and the internet in psoriasis patients

Introduction

Psoriasis significantly affects the patients quality of life, which often leads patients to seek online information about this disease.

Objectives

To explore the habits of patients with psoriasis related to their use of social media (SM) and the internet to obtain information about their disease.

Methods

1,520 patients completed the survey and the Dermatology Life Quality Index (DLQI) questionnaire. The Psoriasis Area Severity Index scores (PASI) and clinical data of the patients were recorded by their physicians.

Results

Of the 1,114 patients that reported using SM and internet, 48.38% regularly and 31.14% sometimes resorted to obtain information about psoriasis. The use of SM and internet for psoriasis was statistically significantly higher among young people (P = 0.000), those with university or higher education (P = 0.009), higher DLQI (P = 0.000) and PASI (P = 0.011) scores, facial (P = 0.050), scalp (P = 0.032), hand (P = 0.048), genital (P = 0.001) and inverse (P = 0.000) involvement, and arthralgia/arthritis (P = 0.006). The participants mostly used the Google (86%) and Facebook (41%). More than half of the participants (62.8%) expected dermatologists to inform society that psoriasis is not contagious.

Conclusions

Internet and SM being widely available and offering substantial information to be easily accessed make it very attractive for patients to use these platforms to investigate diseases, including psoriasis. If what is presented on SM conflicts with what the physician says, patients mostly trust the latter, but at the same time, they tend not to share the results of their online inquiries with their physicians.

Evaluation of the efficacy, safety, and side effects of secukinumab in patients with moderate-to-severe psoriasis: real-world data from a retrospective multicenter study

BACKGROUND

Clinical studies have demonstrated that IL-17A inhibition with secukinumab is effective for clearing the skin of patients with psoriasis and has a favorable safety profile.

OBJECTIVE

The authors aim to determine whether secukinumab is effective and safe for the treatment of moderate-to-severe chronic psoriasis based on clinical experience with this drug.

METHOD

The authors conducted a multicenter retrospective study in nine referral centers and included patients with psoriasis who had received secukinumab between March 2018 to November 2020. Data on demographic characteristics, Psoriasis Area and Severity Index (PASI) scores, and previous treatments were collected from medical records. Patients were evaluated at 12, 24, and 52 weeks with respect to response to treatment and side effects.

RESULTS

In total, 229 patients were recruited for the study. A PASI score improvement of ≥90 points over the baseline was achieved by 79%, 69.8%, and 49.3% of patients at weeks 12, 24, and 52, respectively. The most common adverse events wereCandida infections and fatigue. In total, 74 (32%) patients discontinued treatment by week 52, including due to adverse events, or secondary ineffectiveness.

STUDY LIMITATIONS

Retrospective design.

CONCLUSIONS

These findings suggest that secukinumab therapy is reasonably effective in patients with moderate-to-severe psoriasis. Comorbidities and time length of the disease can affect the response to treatment. The rates of adverse events were high in this patient population.

Adherence to systemic therapy in patients with psoriasis during the COVID-19 pandemic: A multicenter study

Background

Adherence to treatment is important in chronic dermatological diseases. There are limited data regarding the adherence to treatment in patients with psoriasis during the COVID‐19 pandemic.

Aims

We aimed to determine the rates of adherence to systemic treatments in patients with psoriasis and to identify the causes of non‐adherence during the COVID‐19 pandemic.

Methods

We conducted a cross‐sectional multicenter study from May 2021 to August 2021. A questionnaire including items regarding sociodemographic characteristics of the patients, disease‐related characteristics, and treatment‐related characteristics were filled out by the physicians. The Psoriasis Area Severity Index (PASI), Hospital Anxiety, and Depression Scale, and the Dermatology Life Quality Index were calculated. The rate of adherence and non‐adherence to treatment and reasons for non‐adherence to treatment were examined.

Results

A total of 342 patients with psoriasis were included (182 male/160 female) in the study. The mean age of the patients was 45.9 ± 14.2 years. The average duration of psoriasis was 192 ± 134.7 months. While the rate of adherence to treatment was 57.6%, the rate of non‐adherence to treatment was 42.4%. There were no significant differences with respect to adherence to treatment in comparison with oral and injection‐therapy groups. The most frequent reasons for non‐adherence to treatment were inability to go to the hospital (19.2%), concern about the COVID‐19 infection (16.3%), discontinuation of the treatment by the doctor (13.7%), inability to reach the doctor (7.3%), and inability to have access to the medication (7.3%).

Conclusion

Adherence to oral and injection therapies was fairly high among our patients with psoriasis during the COVID‐19 pandemic. Psoriasis severity and duration of medication use had a negative impact on adherence to treatment.

Has the COVID-19 pandemic changed attitudes and behaviors concerning cosmetic care and procedures among patients presenting to the dermatology outpatient clinic? A multicenter study with 1437 participants

Background

The rate of cosmetic procedures and use of skincare products is considered to be affected during the pandemic period; however, this has not been investigated yet.

Objective

To determine whether the ongoing pandemic has changed people's habits related to skincare products and cosmetic procedures.

Methods

We conducted a multicenter survey study covering both private and public hospitals. Sociodemographic characteristics and clinical diagnoses of the patients were noted by dermatologists. A survey was used to determine the type and application areas of skincare products and cosmetic procedures before and during the pandemic, whether the patients were concerned about being infected, and any change in the make‐up habits of female patients.

Results

Of the 1437 patients, 86.7% presented to the hospital due to dermatological complaints and 13.3% for cosmetic procedures. The rate of those that did not use skincare products was 0.05% before and 0.06% during the pandemic. Of the participants, 43.2% had undergone cosmetic procedures before and 38.1% during the pandemic. For both periods, the most frequent cosmetic procedure applied was laser epilation, followed by skincare treatment and chemical peeling. While undergoing these procedures, 34.9% of the patients were concerned about contracting coronavirus.

Conclusion

There was no significant difference in the use of skincare products and cosmetic procedures before and during the pandemic. The majority of the patients continued to undergo these procedures despite their fear of being infected. This shows that during the pandemic period, patients are concerned with their appearance and continue to undergo cosmetic procedures and pay attention to their skincare.

Pigmented purpuric dermatosis: Ten years of experience in a tertiary hospital and awareness of mycosis fungoides in differential diagnosis

BACKGROUND

Pigmented purpuric dermatoses (PPD) can clinically mimic many diseases. Histopathology provides a definitive diagnosis. The aim of the study is to reveal the features of patients with PPD and to determine the disease frequency in the differential diagnosis, especially mycosis fungoides (MF).

METHODS

We retrospectively reviewed records of patients with PPD admitted to our hospital from January 2010 to May 2019. We studied the histopathological features of 127 patients, and performed pattern analysis on cases with a confirmed histopathologic diagnosis of PPD. Among the cases presenting with clinical features of PPD, but displaying different histopathological diagnoses, we focused on MF and tried to clarify the features of PPD-like MF.

RESULTS

Overall, 389 patients were admitted to our hospital with PPD symptoms. Of them, 262 patients were diagnosed clinically and a histopathological examination was performed in 127 patients. Of 127, 87 were diagnosed with PPD, and in the remaining 40, non-specific features (9.4%), vasculitis (6.2%), pityriasis rosea (4.7%), MF (3.9%), suspected-MF (1.5%), and other dermatoses (%5.5) were detected. The biopsy findings of two patients showed PPD, but during follow-up, the diagnosis of MF was established.

CONCLUSIONS

MF should be included in the differential diagnosis of PPD cases presenting with longstanding and widespread involvement.

Case of Olmsted Syndrome with Essential Thrombocytosis Misdiagnosed as Acrodermatitis Enteropathica

Olmsted syndrome is a rare genodermatosis. Palmoplantar keratoderma and periorificial keratodermic plaques are the most important clinical findings. Additional findings associated with a large number of systems may accompany such as teeth, nail deformities, alopecia, mental retardation, and bone-joint anomalies. Therefore, it is difficult to make a differential diagnosis from other palmoplantar keratodermas. It also needs to be differentiated from acrodermatitis enteropathica because of periorificial plaques. The absence of regression in lesions with zinc treatment excludes this disease. We present here an Olmsted syndrome case with essential thrombocytosis for the first time.

Evaluation of the adverse effects of biological agents used in the treatment of psoriasis: A multicenter retrospective cohort study

The objective was to reveal and compare the adverse effects of infliximab, etanercept, adalimumab, ustekinumab and secukinumab, and determine possible risk factors. The follow-up files and computer-based records of patients with psoriasis were retrospectively screened between January 2007 and September 2019. The five biological agents were compared in terms of their adverse effects, and factors that might be related to these effects were explored. While there was no statistically significant difference between the agents in terms of the rate of serious adverse effects, when all the adverse effects were evaluated together, the highest rate was seen in the use of infliximab and the lowest in secukinumab (P = .001). The rates of adverse effects and related drug discontinuation were higher in the use of anti-TNF agents compared to interleukin inhibitors (P = .004 and P = .012, respectively). The agent with the highest drug discontinuation rate due to adverse effects was infliximab while the least discontinued agent was ustekinumab (P = .036). There were more side effects with anti-TNF than interleukin inhibitors, but the serious adverse effect rate was similar in both groups. The incidence of certain adverse effects increases depending on age, number of comorbidities, biological agent and its group, concomitant systemic therapy, and use of multiple agents.

Acne in pregnancy: A prospective multicenter, cross-sectional study of 295 patients in Turkey

BACKGROUND

There are only a few studies on acne in pregnancy. This study was aimed to investigate the demographic, clinical, and familial characteristics of acne in pregnancy, triggering factors including endocrine diseases, and association of these findings with acne in different trimesters of pregnancy.

METHODS

Pregnant women aged 18 years and older with acne at any stage of pregnancy were consecutively interviewed at the participating centers during the study period from 2016 to 2019. Acne severity was evaluated using the Comprehensive Acne Severity Scale.

RESULTS

A total of 295 pregnant women with acne were included, with 167 (56.6%) patients showing mild, 87 (29.5%) moderate, six (12.2%) severe, and five (1.7%) very severe acne. Truncal acne was significantly higher in the third trimester than in the other stages (P < 0.001). Onset of acne before pregnancy, prepubertal, pubertal or adult onset, or acne history in previous pregnancies did not influence acne severity in pregnancy. Women with irregular menstruation before pregnancy, polycystic ovary syndrome, hirsutism, and higher body weight index tended to show severe acne in pregnancy.

CONCLUSIONS

Severe acne during pregnancy is generally uncommon, while severity of facial acne, truncal acne, and hirsutism is higher in the third trimester than in other trimesters. Acne in pregnancy shares many characteristics with female adult acne. Substantial changes in different kinds of hormones play a more complex role in acne during pregnancy, but the pathogenesis remains to be determined.

Switching Biologics in the Treatment of Psoriasis: A Multicenter Experience

BACKGROUND/OBJECTIVE

The purpose of our study was to provide evidence on the treatment choices, reasons, and results of switching between biologic agents in treating patients with psoriasis.

METHODS

We conducted a retrospective database search of six tertiary referral centers for pso-riasis patients between January 2007 and May 2019. We analyzed patient and treatment characteristics of all patients in the registry.

RESULTS

We enrolled 427 psoriatic patients treated with biologics, and 145 (34%) required a switch to another biologic. The reasons for discontinuing the first biologic agent were inefficacy (n = 106, 62.4%), adverse events (n = 28, 16.5%), and others (n = 36, 21.2%). At week 12, there was a 67.7% reduction in the Psoriasis Area and Severity Index (PASI) score of patients treated with their first biologic, and 51.4% reduction for the second. A drug survival analysis showed no statistically significant difference between the drug survival of first-line biologic agents, but ustekinumab had the highest survival rate among second-line biologics (log-rank p = 0.010). Multivariate analyses for overall drug discontinuation showed that the occurrence of psoriatic arthritis (OR: 1.883, 95% CI: 1.274-2.782, p = 0.001), nail involvement (OR: 2.334, 95% CI: 1.534-3.552, p < 0.001), and use of concomitant treatment (OR: 2.303, 95% CI: 1.403 -3.780, p = 0.001) are predictors for discontinuation.

CONCLUSION

Discontinuation of treatment was most commonly due to inefficacy. Patients who switched to a different biologic agent showed a similar improvement in PASI scores compared to biologic-naive patients. Switching to a second biologic therapy due to inefficacy or adverse events caused by the first one may improve psoriasis.

Multifactorial Painful Leg Ulcers Due to Hyperhomocysteinemia, Plasminogen Activator Inhibitor-1 4G/5G Heterozygote Gene Mutation, and Beta Thalassemia Minor: A Case Report

Leg ulcers may occur due to many autoimmune, hereditary, inflammatory, and infectious causes including venous, arterial, and neuropathic ulcers. Hyperhomocysteinemia is a metabolic disorder caused by various enzyme defects in methionine metabolism. The most common cause is methylenetetrahydrofolatreductase (MTHFR) enzyme gene mutations. Hyperhomocysteinemia is an independent risk factor for deep vein thrombosis and peripheral arterial disease. The effects of endothelial cell damage on smooth muscle hypertrophy, platelet aggregation, coagulation, and fibrinolysis cause atherogenesis and thrombosis, leading to venous and arterial lower extremity ulcers. In this article, we report the case of a 47-year-old male patient who was admitted to our clinic due to painful leg ulcers that started 1 year ago. He had a history of vena cava inferior thrombosis, deep vein thrombosis, and 40 pack-year smoking. Histopathological examination of punch biopsy taken from ulcerative lesion showed intense inflammatory infiltration in the middle dermis, erythrocyte extravasation, leukocytoclasia, and thrombus formation in a small diameter venule lumen. There were nonspecific findings in direct immunofluorescence examination. He was found as having MTHFR C677T homozygote and plasminogen activator inhibitor-1 4G/5G heterozygote gene mutation with high homocysteine level of 22.90 µmol/L, and he was diagnosed as hyperhomocysteinemia. He was recommended to quit smoking because it triggered thrombosis in hyperhomocysteinemia. Herein, we present a case of hyperhomocysteinemia due to MTHFR mutation, which is one of the rare hereditary thrombophilia causes.

Coexistence of morphea and granuloma annulare: a rare case report

CONTEXT

Localized scleroderma (morphea) is characterized by fibrosis of skin and subcutaneous tissue. Granuloma annulare is a relatively common disease that is characterized by dermal papules and arciform plaques.

CASE REPORT

Here, we present the case of a 42-year-old woman who developed granuloma annulare on the dorsum of her feet and abdominal region, and morphea on the anterior side of her lower limbs. We also discuss the etiological and pathogenetic processes that may cause the rare coexistence of these two diseases.

CONCLUSION

Only a few cases in the literature have described coexistence of morphea and granuloma annulare.

Are Dermatophytid Reactions in Patients with Kerion Celsi Much More Common Than Previously Thought? A Prospective Study

Dermatophytid reactions are secondary eruptions in response to dermatophytosis. Only a few cases demonstrating an association between dermatophytid reactions and tinea capitis have been reported. Dermatophytid reactions were evaluated in patients diagnosed with kerion celsi. Patients admitted to the dermatology clinic of Van Regional Training and Research Hospital between November 22, 2012, and July 1, 2013, diagnosed with kerion celsi were evaluated for dermatophytid reactions. Six girls (32%) and 13 boys (68%) were included in this study. Dermatophytid reactions were detected in 13 of the 19 patients (68%). Seven patients (36.84%) had eczematous patches or plaques and three (15.8%) had papules. Eczematous lesions, papules, and pustules were noted in two patients (10.5%) and one (5.3%) had signs of an angioedema-like reaction. Dermatophytid reactions in all patients were observed before the initiation of therapy. According to our clinical experiences, dermatophytid reactions in patients with kerion celsi were more common than reported. Eczematous scaly patches or plaques were the most frequently seen forms of dermatophytid in patients with kerion celsi. Dermatophytid reactions may occur before or after initiation of systemic antifungal therapy. Recognition of this reaction is important so that dermatophytids can be distinguished from drug reactions and the decision can be made whether to continue or to stop the systemic antifungal treatment.

Genital involvement in pemphigus vulgaris (PV): correlation with clinical and cervicovaginal Pap smear findings

BACKGROUND

The frequency of genital involvement in pemphigus vulgaris (PV) has not been clearly defined.

OBJECTIVES

We sought to evaluate the frequency of cervical, vaginal, and vulvar involvement in PV and to determine their association with genital symptoms, clinical involvement, and cytological status.

METHODS

The current study's sample included 34 female patients with PV. Gynecologic and ear, nose, and throat examinations and indirect immunofluorescence analyses were performed, and Pap smears were collected.

RESULTS

Genital involvement was observed in 44.1% of patients. It was significantly associated with disease severity and clinical involvement. Pharyngeal involvement was observed in 61.8% of patients and was the second-most frequently involved mucosal region. Genital involvement was significantly associated with nasal mucosa involvement. Cervicovaginal Pap smears showed acantholytic cells of PV in 35.3% of patients.

LIMITATION

The sample size is small.

CONCLUSION

Genital involvement in PV is not rare. Genital mucosa is the most affected mucosal region after oral and pharyngeal mucosa. Furthermore, genital involvement is significantly associated with nasal involvement and genital symptoms. The need for complete gynecologic evaluations of patients with PV, nasal involvement, and genital symptoms is emphasized.

A CD30(-) Transformed Mycosis Fungoides Case Responding Very Well to Systemic Bexarotene and Methotrexate

The course of mycosis fungoides (MF) is indolent except when transformation to a large T-cell lymphoma occurs. The diagnosis of transformed MF relies on the presence of more than 25% of large cells on biopsy of an MF lesion. Treatment of transformed MF is a major challenge as these patients have poor outcome. Here, we report a 61-year-old man presenting with tumoral ulcer on the plantar area of the foot who was diagnosed cutaneous CD30(-) large cell transformed MF and treated with systemic methotraxate and bexarotene therapy.

A case of hyperpigmentation and acanthosis nigricans by testosterone injections

Drug-related skin disorders may occur in many different ways. Despite pigmentary changes being less important for morbidity, these changes precipitate depressed mood and reduce self-confidence. Testosterone is a steroid hormone from the androgen group and primarily used for the treatment of hypogonadism in males. Testosterone replacement can cause skin problems like acne, hair loss, redness, pain, or infection at the injection site.

The study was conducted on a 49-year-old man with adult onset idiopathic hypogonadotropic hypogonadism, which is an acquired form of isolated gonadotropin-releasing hormone deficiency. He was presented with lack of energy and decreased sexual function 10 years ago and was given an oil-based injectable blend of four esterized testosterone compounds as hormone replacement treatment in a urology polyclinic. He was referred to our polyclinic by endocrinologist because of progressive hyperpigmentation marked on his face and oral mucosa. In the present study, we report the first testosterone therapy-related facial and oral mucosal hyperpigmentation and acanthosis nigricans in the same patient.

PUVA phototherapy-induced secondary amyloidosis in patients with mycosis fungoides: a rare adverse effect of phototherapy

AIM

Amyloidosis is a common disorder in adults. Secondary amyloidosis in patients with mycosis fungoides (MF) after photochemotherapy with 8-methoxypsoralen followed by ultraviolet A (PUVA) treatment has not been reported. Our aim is to describe the clinical and histological features of PUVA phototherapy-induced secondary amyloidosis.

MATERIALS AND METHODS

Sixty-one patients with MF treated with PUVA phototherapy were analyzed clinically and pathologically and by staining with Congo red and crystal violet.

RESULTS

Of 61 patients, 5 met the study criteria. Secondary amyloidosis was detected in 5 patients treated with PUVA. The secondary amyloidosis appeared after a mean of 56 exposures (range: 30--81) and a mean cumulative PUVA radiation dose of 131.7 J/cm2 (range: 31-305.5). The mean follow-up duration from the date of occurrence of the secondary amyloidosis was 18.2 weeks (range: 10-30). Histologically, vacuolar interface changes, colloid bodies, and melanophages were seen in all 5 patients. There were 4 patients who had perivascular lymphocytic infiltration and 1 patient had lichenoid lymphocytic infiltration.

CONCLUSION

It should be noted that secondary amyloidosis can be present in patients who have been treated with PUVA therapy and it can be a result of the apoptotic effect of PUVA on the basal keratinocytes.