Does the risk of basal cell carcinoma increase in patients with psoriasis under treatment?

BACKGROUND

Psoriasis is a common, chronic, inflammatory disease. Although it mainly affects the skin, it has been associated with a large number of comorbidities. In addition to comorbidities such as depression and psoriatic arthritis, it is known that there is an increased prevalence of cancer in psoriasis patients. Skin cancers, particularly squamous cell carcinoma, have been associated with psoriasis. However, basal cell carcinoma data are limited.

METHODS

346 psoriasis patients and 306 individuals were selected as the control group. There were no differences between the patient and control groups in terms of age and gender. The mean age of the psoriasis patients was 49.9 ± 15.8 years and the control group was 49.4 ± 13.4 years. Sociodemographic data of the patients were recorded. Pharmacological agents used in the treatment of psoriasis were included in the analysis. Disease severity was assessed by the psoriasis area severity index (PASI). In the physical examination of the patients, biopsies were taken from lesions suspicious for BCC. BCC diagnosis was made by histopathologically.

RESULTS

The frequency of BCC was higher in psoriasis patients than in the control group (6.6% vs. 2.9%, p < .001). Advanced age (p < .001), smoking (p = .003), and arthritis (p < .001) were associated with BCC in psoriasis patients. However, there was no relationship between PASI and BCC (p = .142). Among the psoriasis treatments, only UV therapy was associated with BCC (p = .038). The frequency of PUVA (p < .001) and number of PUVA session (p = .010) was higher in psoriasis patients with BCC rather than NB-UVB.

CONCLUSION

The frequency of BCC is increased in psoriasis patients. Psoriasis is associated with an increased risk of BCC, especially when treated with PUVA therapy for a long time.

Effects of psoriasis and psoralen exposure on the somatic mutation landscape of the skin

Somatic mutations are hypothesized to play a role in many non-neoplastic diseases. We performed whole-exome sequencing of 1,182 microbiopsies dissected from lesional and nonlesional epidermis from 111 patients with psoriasis to search for evidence that somatic mutations in keratinocytes may influence the disease process. Lesional skin remained highly polyclonal, showing no evidence of large-scale spread of clones carrying potentially pathogenic mutations. The mutation rate of keratinocytes was similarly only modestly affected by the disease. We found evidence of positive selection in previously reported driver genes NOTCH1, NOTCH2, TP53, FAT1 and PPM1D and also identified mutations in four genes (GXYLT1, CHEK2, ZFP36L2 and EEF1A1) that we hypothesize are selected for in squamous epithelium irrespective of disease status. Finally, we describe a mutational signature of psoralens-a class of chemicals previously found in some sunscreens and which are used as part of PUVA (psoralens and ultraviolet-A) photochemotherapy treatment for psoriasis.

Phototherapy: Theory and practice

Despite the development of highly effective biologics for skin diseases such as psoriasis or atopic dermatitis, UVA and UVB therapy, alone or in combination, are still essential components of various guidelines. Phototherapy is not only a first-line treatment and highly effective for a number of skin diseases, but is also economical and has few side effects. The targeted use of UVA and UVB, if necessary, in combination with the photosensitizer psoralen in the context of PUVA therapy, enables the dermatologist to effectively treat a wide variety of skin diseases. Indications for phototherapy include epidermal diseases such as atopic dermatitis, psoriasis and vitiligo, as well as photodermatoses, mycosis fungoides, graft-versus-host disease and deep dermal diseases such as scleroderma. This article reviews the physical principles, molecular mechanisms, current treatment regimens, and individual indications for phototherapy and photochemotherapy.

A retrospective, descriptive study of patients with Mycosis fungoides treated by phototherapy (oral PUVA, NB-UVB) with a twice-weekly regimen at the Institute of Dermatology, Bangkok, Thailand, with an experiential timeline of 13 years

BACKGROUND

Phototherapy has been a first-line treatment for early-stage mycosis fungoides (MF) since 1976. Oral 8-methoxypsoralen plus ultraviolet A (oral PUVA) and narrow-band ultraviolet B (NB-UVB) are favorable modalities owing to their availability. In previous studies, phototherapy was conducted thrice per week initially, which is not feasible for many patients.

OBJECTIVES

To evaluate the initial clinical responses and time to relapse in patients with early-stage MF treated with oral PUVA and NB-UVB at a twice-weekly regimen.

METHODS

We reviewed the records of patients with biopsy-proven MF who received oral PUVA or NB-UVB in 2002-2014. Demographic data, staging, response to initial course of phototherapy, and initial relapse-free interval were collected.

RESULTS

Among 70 patients, 14 (20%) and 56 (80%) were treated with oral PUVA and NB-UVB, respectively. The majority had early-stage MF (IA, 22.9%, IB, 57.1%, and IIA, 4.3%). Oral PUVA led to a complete response (CR) in 2 (14.3%) patients and partial response (PR) in 7 (50%) patients; 17 (30.4%) and 25 (44.6%) patients, respectively, achieved CR and PR with NB-UVB. The number of treatments was similar in both groups. The cumulative dose was 520.7 J/cm² for PUVA and 41.6 J/cm² for NB-UVB. There was no initial relapse in the 2 (100%) patients and in 10 (58.8%) patients treated with oral PUVA and NB-UVB at 18 months and 9.14 months of follow-up, respectively.

CONCLUSION

Patients with early-stage MF can achieve clinical response with oral PUVA and NB-UVB, with a twice per week regimen. The initial relapse-free interval was longer than 1 year.

Pathophysiology, Clinical Presentation, and Treatment of Psoriasis: A Review

IMPORTANCE

Approximately 125 million people worldwide have psoriasis. Patients with psoriasis experience substantial morbidity and increased rates of inflammatory arthritis, cardiometabolic diseases, and mental health disorders.

OBSERVATIONS

Plaque psoriasis is the most common variant of psoriasis. The most rapid advancements addressing plaque psoriasis have been in its pathogenesis, genetics, comorbidities, and biologic treatments. Plaque psoriasis is associated with a number of comorbidities including psoriatic arthritis, cardiometabolic diseases, and depression. For patients with mild psoriasis, topical agents remain the mainstay of treatment, and they include topical corticosteroids, vitamin D analogues, calcineurin inhibitors, and keratolytics. The American Academy of Dermatology-National Psoriasis Foundation guidelines recommend biologics as an option for first-line treatment of moderate to severe plaque psoriasis because of their efficacy in treating it and acceptable safety profiles. Specifically, inhibitors to tumor necrosis factor α (TNF-α) include etanercept, adalimumab, certolizumab, and infliximab. Other biologics inhibit cytokines such as the p40 subunit of the cytokines IL-12 and IL-13 (ustekinumab), IL-17 (secukinumab, ixekizumab, bimekizumab, and brodalumab), and the p19 subunit of IL-23 (guselkumab, tildrakizumab, risankizumab, and mirikizumab). Biologics that inhibit TNF-α, p40IL-12/23, and IL-17 are also approved for the treatment of psoriatic arthritis. Oral treatments include traditional agents such as methotrexate, acitretin, cyclosporine, and the advanced small molecule apremilast, which is a phosphodiesterase 4 inhibitor. The most commonly prescribed light therapy used to treat plaque psoriasis is narrowband UV-B phototherapy.

CONCLUSIONS AND RELEVANCE

Psoriasis is an inflammatory skin disease that is associated with multiple comorbidities and substantially diminishes patients' quality of life. Topical therapies remain the cornerstone for treating mild psoriasis. Therapeutic advancements for moderate to severe plaque psoriasis include biologics that inhibit TNF-α, p40IL-12/23, IL-17, and p19IL-23, as well as an oral phosphodiesterase 4 inhibitor.

Psoriasis and Treatment: Past, Present and Future Aspects

The management of psoriasis has evolved considerably over the past 100 years. This has occurred in parallel with our understanding of the pathogenesis of this common, complex and enigmatic disease. It should be celebrated as an outstanding example of successful translational research. With precise targeting of immune pathways for the treatment of psoriasis with new biologics and small molecules has come the realisation that the most effective approach to patient management is a holistic one which encompasses the biopsychosocial nature of the disease. This involves a stratified medicine approach to identifying the best drug for an individual allied to patient education, screening for comorbidity, and regular review as both the clinical presentation and the patient's needs will change over time. Al-though there is not yet a cure for psoriasis - the whole person, systems approach to patient management, that is in part dependent on early intervention, should help to ensure an optimal outcome.

Therapeutic Efficacy of Etretinate on Cutaneous-type Adult T-cell Leukemia-Lymphoma

Cutaneous-type adult T-cell leukemia-lymphoma is treated with antiviral or skin-directed therapy. Medications that are used to treat skin lesions of cutaneous T-cell lymphomas are also used for the cutaneous-type adult T-cell leukemia-lymphoma. Etretinate, a synthetic retinoid, has been used for treating cutaneous T-cell lymphomas; however, its clinical effectiveness for the treatment of cutaneous-type adult T-cell leukemia-lymphoma has not been fully studied. We conducted a retrospective assessment of the efficacy and safety of etretinate in 9 patients with cutaneous-type adult T-cell leukemia-lymphoma. Complete and partial responses to etretinate were observed in 1 and 7 patients, respectively. Among the responders, remission was maintained for more than 6 years in 2 patients. These results suggest that etretinate is a promising treatment option for cutaneous-type adult T-cell leukemia-lymphoma.

[Treatment of mycosis fungoides and Sézary syndrome]

Adequate therapeutic management of cutaneous T-cell lymphoma (CTCL) requires the identification of the exact CTCL stage and entity within the current WHO classification. There is no curative therapy for CTCL yet, so that treatment currently aims at improving symptoms and quality of life as well as reducing relapse rates. The treatment has to be stage-adapted. Therapeutic options comprise skin-directed as well as systemic treatment. In early stages, phototherapy and local steroids are the first-line therapeutic options. For the therapy of higher stages, interferon alpha and the RXR-specific retinoid bexarotene are used as first-line medications. Second-line treatment comprises monochemotherapy with agents like gemcitabine or liposomal doxorubicine. Nevertheless, the high relapse rates in higher stages make novel alternative treatment options necessary. As future therapy, especially the fusion protein brentuximab-vedotin directed against CD30 shows promising potential in clinical studies.

Treatment of Early Folliculotropic Mycosis Fungoides with Special Focus on Psoralen plus Ultraviolet A

Data on the treatment of early folliculotropic mycosis fungoides, a recently defined clinicopathological subgroup of folliculotropic mycosis fungoides with an indolent course, is limited. Treatment outcomes were studied in a retrospective cohort of 47 adults with early folliculotropic mycosis fungoides, with a focus on psoralen plus ultraviolet A (PUVA) monotherapy, including dosimetric data, and the findings were compared with data for PUVA in 18 adults with early-classic mycosis fungoides. PUVA was given to 27 patients with early folliculotropic mycosis fungoides: 70% achieved complete response and 26% partial response. Significantly more treatments were needed to achieve complete response in stage IB compared with stage IA. There was no significant difference in the complete response rate from classic plaque-stage disease, although the early folliculotropic mycosis fungoides group required more treatments to achieve complete response, and a higher cumulative dose of UVA. Thus, PUVA is an effective treatment for early folliculotropic mycosis fungoides. Its complete response rate might be equal to early-classic mycosis fungoides; however, a longer induction phase is needed to achieve complete response.

Long-term real-life safety profile and effectiveness of fumaric acid esters in psoriasis patients: a single-centre, retrospective, observational study

BACKGROUND

Fumaric acid esters (FAEs) are an established systemic treatment for moderate-to-severe psoriasis. However, the long-term clinical safety and effectiveness of continuous FAE monotherapy and combination therapy have not been established.

OBJECTIVE

To examine the long-term safety and effectiveness of FAEs as monotherapy and in combination with phototherapy or methotrexate in patients with psoriasis treated at a single centre in Germany.

METHODS

This monocentric, retrospective observational study, with a follow-up period of up to 32.5 years, included 859 patients: 626 received FAE monotherapy, 123 received FAEs with concomitant phototherapy and 110 received FAEs with methotrexate.

RESULTS

Approximately half of patients (49.0%) reported adverse events (566 total events), most of which involved the gastrointestinal tract. Serious adverse events were reported in 2.3% of patients, but none were deemed to have a causal relationship with any of the treatment regimens. Adverse events leading to treatment discontinuation were observed in 12.9% of patients. A median duration of 1 year was observed in all three treatment subcohorts (P = 0.70) from initiation of FAE treatment to a 50% response rate, where response was defined as achieving a cumulative static Physician's Global Assessment (PGA) score of 'light' and at least a 2-point reduction in baseline PGA. A 50% response rate for the cumulative Psoriasis Area and Severity Index 75 was achieved in the FAE monotherapy subcohort after a median of 3 years of treatment, in the FAEs + phototherapy subcohort after 6.7 years and in the FAEs + methotrexate subcohort after 8.1 years (P = 0.001).

CONCLUSION

According to our data, FAEs as monotherapy or in combination with phototherapy or methotrexate are safe and beneficial for long-term clinical use. However, multicentre, randomized controlled trials are required to establish the clinical value of monotherapy versus combination therapy and the optimal treatment duration.

8-Methoxypsoralen Plus Ultraviolet A Reduces the Psoriatic Response to Imiquimod in a Murine Model

The effects of 8-Methoxypsoralen plus ultraviolet A (PUVA) or ultraviolet B (UVB) alone on imiquimod-induced psoriasis were examined in a mouse model. Mouse skin was treated with repetitive sub-phototoxic doses of PUVA or UVB before or during the induction of toll-like receptor 7/8 activation and psoriasis through the application of imiquimod. PUVA, to a greater degree than UVB, suppressed the established imiquimod-induced psoriatic phenotype, but pretreatment with PUVA prior to administration of imiquimod also reduced the susceptibility of murine skin to respond to imiquimod to a greater degree than did pretreatment with UVB. PUVA downregulated baseline levels of miRNA27a and 29a, as well as interferon-γ, interleukin-17 and -9, cytokines, which drive psoriatic inflammation. Microarray analysis showed enrichment of senescence pathway genes linked to upregulation of p16/p21 proteins after PUVA pretreatment. However, the anti-psoriatic effect of PUVA was lost when there was an interval of 7 days between final exposure to PUVA and the start of administration of imiquimod. This indicated that (UVB and) PUVA diminished imiquimod-induced established psoriatic inflammation, but also primed the skin in favour of a reduced responsiveness to toll-like receptor activation.

Treatment of Scleroedema Adultorum Buschke: A Systematic Review

Scleroedema adultorum Buschke is a rare skin disease, which can be divided into 3 subtypes: classic type, occurring after respiratory infections; a type lacking association with infections; and a type associated with diabetes. Scleroedema adultorum Buschke is characterized by thickening and tightening of the skin, which typically starts at the neck. In half of patients, spontaneous remission may occur. The aim of this systematic review is to summarize all reported treatments for scleroedema adultorum Buschke, based on articles from PubMed database, using the query "scleroedema adultorum Buschke treatment", English and German, published between 1970 and 2016 and documenting adequate treatments. The results are based mainly on individual case reports, small case series, and retrospective studies often reporting unsuccessful results. Treatment options include topical as well as systemic treatments, and physical modalities. There is a need for randomized controlled trials and studies on long-term outcomes after treatment.

Incidence and Prevalence of Psoriasis in Denmark

The incidence and temporal trends of psoriasis in Denmark between 2003 and 2012 were examined. There was a female predominance ranging between 50.0% (2007) and 55.4% (2009), and the mean age at time of diagnosis was 47.7-58.7 years. A total of 126,055 patients with psoriasis (prevalence 2.2%) were identified. Incidence rates of psoriasis (per 100,000 person years) ranged from 107.5 in 2005 to a peak incidence of 199.5 in 2010. Incidence rates were higher for women, and patients aged 60-69 years, respectively. Use of systemic non-biologic agents, i.e. methotrexate, cyclosporine, retinoids, or psoralen plus ultraviolet A (PUVA) increased over the study course, and were used in 15.0% of all patients. Biologic agents (efalizumab, etanercept, infliximab, adalimumab, or ustekinumab) were utilized in 2.7% of patients. On a national level, incidence of psoriasis fluctuated during the 10-year study course. The relationship between psoriasis incidence and age appeared to be relatively linear, and disease prevalence was comparable to that in other European countries.

Disseminated punctate keratoderma: a rare case report and review of the literature

We report a rare case of a 53-year-old womanpresenting with diffuse, late-onset disseminatedhyperkeratotic papules. Biopsy showed massivehyperkeratosis overlying a crateriform epidermaldepression and hypergranulosis with mild epidermalhyperplasia. There was no parakeratosis, cornoidlamella, or dyskeratosis. Based on the clinical findingsand histopathological features, a diagnosis ofdisseminated punctate keratoderma was made. Thisis a rare subtype of palmoplantar keratoderma, whichhas a putative increased risk of malignancy. This casereport emphasizes the importance of identifyingthe clinical and histological presentation of this rarecondition; referral of the patient for age-appropriatemalignancy screening is appropriate. We also presenta concise review of treatment options.

Considerations for Systemic Treatment of Psoriasis in Obese Patients

Psoriasis is an immune-mediated inflammatory skin disease frequently associated with metabolic disorders, including diabetes, dyslipidaemia and metabolic syndrome. Moreover, a growing number of studies confirm the association between psoriasis and obesity. It has been found that obesity, as measured by body mass index >30 kg/m², can double the risk of incident psoriasis. A positive correlation between different measures of adiposity and the severity of psoriasis has also been reported. Epidemiologic studies have also provided robust evidence confirming the association between obesity and psoriatic arthritis. Genetic, metabolic and environmental factors are all likely to contribute to these associations. Adipose tissue is an active endocrine and paracrine organ that has a key role in lipid and glucose metabolism as well as inflammation. Fat tissue is traditionally distributed into two main compartments with different metabolic characteristics, i.e. the subcutaneous and visceral adipose tissue. Particular attention has been devoted to visceral adiposity because of its contribution to inflammation and atherosclerosis. The association between psoriasis and obesity should be properly considered when choosing a systemic treatment, because it could exert negative effects on metabolic parameters, including liver enzymes, serum lipids and renal function. Obesity may increase the risk of liver and renal toxicity from methotrexate and cyclosporine. Moreover, obesity can compromise the effectiveness of systemic treatments for psoriasis (conventional and biological therapies). Dermatologists are also expected to promote a healthy lifestyle and weight loss for obese patients because they could improve metabolic parameters and responsiveness to psoriasis therapies.

Psoriasis in Latin America

During the last few decades, management of psoriasis has changed worldwide, owing to a better understanding of its pathophysiology and the introduction of new treatments. As experts in the field of dermatology, specialists from Latin America collaborated to develop this review and further provide an update on the current state of psoriasis management in Latin America. With the goal of summarizing the latest information on psoriasis in most countries in Latin America, we conducted a literature search to obtain relevant articles published in the medical/scientific literature in Latin American countries over the last 10 years; in addition, we completed a questionnaire comprised of 20 questions on important issues related to psoriasis. The aim of this final document isto help improve understanding and management of the disease and to help patients gain better access to new approaches and medical solutions.

Serotonin signalling is crucial in the induction of PUVA-induced systemic suppression of delayed-type hypersensitivity but not local apoptosis or inflammation of the skin

Psoralen and UVA (PUVA) has immunosuppressive and proapoptotic effects, which are thought to be responsible alone or in combination for its therapeutic efficacy. However, the molecular mechanism by which PUVA mediates its effects is not well understood. Activation of the serotonin (5-hydroxytryptamine, 5-HT) pathway has been suggested to be involved in the modulation of T-cell responses and found to mediate UVB-induced immune suppression. In particular, the activation of the 5-HT2A receptor has been proposed as one mechanism responsible for UV-induced immune suppression. We therefore hypothesized that 5-HT may play a role in PUVA-induced effects. The model of systemic suppression of delayed-type hypersensitivity (DTH) to Candida albicans was used to study immune function after exposure of C3H and KIT(W) (-Sh/W-Sh) mice to a minimal inflammatory dose of topical PUVA. The intra-peritoneal injection of the 5-HT2 receptor antagonist ketanserin or cyproheptadine or an anti-5-HT antibody immediately before PUVA exposure entirely abrogated suppression of DTH but had no significant effect on inflammation, as measured by swelling and cellular infiltration of the skin, and apoptosis as determined by the number of sunburn cells in C3H mice. Importantly, the systemic injection of 5-HT recapitulated PUVA immune suppression of DTH but did not induce inflammation or apoptosis in the skin. KIT(W) (-Sh/W-Sh) mice (exhibiting myelopoietic abnormalities, including lack of 5-HT-containing mast cells) were resistant to PUVA-induced suppression of DTH but not local skin swelling. Thus, this points towards a crucial role of 5-HT signalling in PUVA-induced immune suppression but not inflammation or apoptosis in situ in the skin.

Non-Invasive Evaluation of Tacalcitol Plus Puva versus Tacalcitol Plus UVB-NB in the Treatment of Psoriasis: “Right-Left Intra-Individual — Pre/Post Comparison Design”

Photochemotherapy with psoralen plus ultraviolet A (PUVA) and phototherapy with UVB narrow band (UVB-NB) are used in the treatment of psoriasis. Numerous studies have shown that the additional administration of either topical or systemic antipsoriatic agents may effectively increase the efficacy of these therapies. This study aimed to compare through objective data the efficacy of topical tacalcitol in combination with PUVA or UVB-NB versus PUVA and UVB-NB monotherapy in the treatment of mild to moderate chronic plaque psoriasis. Modified Psoriasis Area and Severity Index (PASI) score, transepidermal water loss (TEWL) and stratum corneum hydration were used to monitor the restoration of skin barrier in the psoriatic plaques of 40 patients during photochemotherapy. The study was a right-left, intra-individual, pre/post comparison trial. PUVA and UVB-NB treatments were given three times a week. On those plaques localized on the right side of the body tacalcitol ointment was applied once a day, in the evening. Corneometry, TEWL and modified PASI score were used to evaluate the response to the treatment at baseline, one month and two months. Thirty-six of the forty enrolled subjects completed the study. The comparison between combination treatments and the PUVA/UVB-NB monotherapy showed no significant differences with regard to modified PASI index. However, significant differences were recorded with regard to TEWL and corneometry. The combination of tacalcitol plus PUVA or tacalcitol plus UVB-NB restored epidermal barrier functions as well as skin hydration faster than PUVA or UVB-NB monotherapy (TEWL: p=0.0050 and corneometry: p=0.003). The combination of tacalcitol plus UVB-NB allowed a better restoration of skin barrier functions than tacalcitol plus PUVA (p=0.013). In conclusion, the combination of tacalcitol plus PUVA or plus UVB-NB improves the therapeutic result. In addition, the data from TEWL and skin hydration suggest a means in which tacalcitol plus UVB-NB induces a better normalization of skin biophysical parameters.

Mycosis Fungoides with Tinea Pseudoimbricata Owing to Trichophyton Rubrum Infection

Background:

Dermatophytes can mimic or possibly trigger mycosis fungoides (MF).

Objectives:

To present the case of a 55-year-old male referred for MF refractory to therapy who instead had extensive tinea pseudoimbricata (concentric, annular lesions secondary to Trichophyton rubrum).

Methods:

Case report with biopsy and cultures.

Results:

Oral antifungal therapy dramatically improved his lesions, and only a few MF lesions persisted after treatment.

Conclusions:

Concurrent tinea may confound the treatment and diagnosis of MF.

Mycosis Fungoides: A Retrospective Study of 44 Swedish Cases

Mycosis fungoides (MF) is a primary cutaneous T-cell lymphoma with slow disease progression. There is a lack of descriptive data from Sweden concerning patients with this diagnosis. This study extracted data on patients admitted to the dermatology department at Lund University Hospital, Sweden from 1996 to 2010. Forty-four patients with clinically and histopathologically verified MF were identified during the period, with a mean follow-up time of 5.6 years. Median age at initial diagnosis was 64 years. In several cases other skin diseases preceded MF onset, such as non-specific dermatitis (32%) and parapsoriasis (30%). The majority of patients (86%, n = 38) had limited-stage (IA-IB) disease at the time of diagnosis. Overall response rate to psoralen plus ultraviolet A (PUVA) treatment was 81%. In adnexal MF, a trend to higher rate of progression to an advanced stage was observed when compared with non-adnexal disease (40% and 21%, respectively). Increased levels of soluble interleukin-2 (IL-2) receptor correlated with disease stage, being elevated in advanced stages or adnexal disease, but almost never elevated in early non-adnexal limited-stage disease. Overall mortality was 25%, but only 11% could be verified as caused by MF.

Ultraviolet B Phototherapy for Psoriasis: Review of Practical Guidelines

Psoriasis is an inflammatory skin condition that affects approximately 2 % of people worldwide. Topical treatments, systemic treatments, biologic agents, and phototherapy are all treatment options for psoriasis. Ultraviolet (UV) B phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments. This review outlines the use, dosage, safety, and efficacy of narrowband UVB (NB-UVB) and targeted phototherapy. NB-UVB and excimer laser are effective treatment options for psoriasis; they are administered two to three times weekly until clearance followed by maintenance treatment before discontinuation. Long-term data on NB-UVB indicate that it has a good safety profile. NB-UVB is commonly used with adjunctive topical treatments such as emollients, calcipotriene, cortico-steroids, retinoids, and tar. NB-UVB can be used in selected patients with traditional systemic agents such as methotrexate, mycophenolate mofetil, and cyclosporine, although the duration of the combined treatment should be kept to a minimum and patients need to be closely monitored. Acitretin can be safely used with phototherapy, but robust data on the combination use of biologic agents or phosphodiesterase inhibitors with phototherapy are lacking.

Update on treatment of photodermatosis

Photodermatoses are a group of skin conditions associated with an abnormal reaction to ultraviolet (UV) radiation. There are several of the photosensitive rashes which mainly affect the UV exposed areas of the skin. It can be classified into four groups: immunology mediated photodermatoses, chemical and drug induced photosensitivity, photoaggravated dermatoses, and genetic disorders. A systematic approach including history, physical examination, phototesting, photopatch testing, and laboratory tests are important in diagnosis of a photodermatosis patient. In order to optimally treat a disease of photodermatoses, we need to consider which treatment offers the most appropriate result in each disease, such as sunscreens, systemic medication, topical medication, phototherapy, and others. For all groups of photodermatoses, photoprotection is one of the essential parts of management. Photoprotection, which includes sunscreening and wearing photoprotective clothing, a wide brimmed hat, and sunglasses, is important. There are also promising emerging photoprotective agents.

[Efficacy and safety of topical PUVA treatment for refractory lesions of mycosis fungoides]

OBJECTIVE

To evaluate the efficacy and safety of topical PUVA treatment of refractory lesions of mycosis fungoides.

METHODS

From January 2008 to 2014, a total of 10 patients (4 males and 6 females) with mycosis fungoides were treated with topical PUVA in Peking Union Medical College Hospital, including 7 cases in plaque stage and 3 cases in tumor stage. The average number of lesions were 1.9±0.9. The median age of these patients was (46.0±9.4) years. The average course of disease was (12.4±7.7) years. Psoralen was applied topically on treatment area 30 min before total body UVA irradiation treatment, 3 times a week. And the efficiency and safety of the therapy were evaluated.

RESULTS

All the patients were treated with topical PUVA with a median total dose of (161.60±135.96) J/cm2 in an average of (18.10±14.61) fractions. Total dose of UVA was (1 953.25±829.73) J/cm2, and total number of treatment was (261.90±116.79) fractions. The total treatment time was (45.80±26.64) months. Complete clinical response (CR) rate was 60.0%, partial response (PR) rate was 30.0%, and the overall response rate (CR+PR) was 90.0%. One patient showed no response. No severe acute or chronic side effects were observed.

CONCLUSION

Topical PUVA therapy is effective in the treatment of refractory lesions of mycosis fungoides with little severe side effects.

Scleredema Diabeticorum - A Case Report

Buschke Scleredema is a rare connective tissue disorder of unknown aetiology and characterized by thickening of the dermis. It resembles systemic sclerosis, eosinophilic fasciitis and cutaneous amyloidosis. Scleredema may be associated with a history of an antecedent febrile illness, diabetes mellitus, or blood dyscrasia. It may be classified into three clinical groups, each has a different history, course, and prognosis. Histology of skin is characterized by thickened dermis and increased spaces between large collagen bundles due to increased deposition of mucopolysaccharide in the dermis. Differential diagnosis can be made considering the typical clinical features and the histological peculiarity. No therapy is effective. In this communication we have presented a 54 year old man with scleredema successfully treated by PUVA and methotrexate. We reviewed associated diseases, clinical and histopathological characteristics, evolution and response to treatment.

Regulation mechanisms of hair growth

The dorsal resting hair of C3H mice at various ages was shaved, thus activating the hair into the anagen stage. New hair growth after shaving was not uniform in the various age groups. Furthermore, an increasing delay in hair regrowth was observed as the mice became older (20, 66, 188, and 312 days). In the biochemical analysis of hair regrowing and nongrowing skins after shaving, activities of ornithine decarboxylase, transglutaminase, and alkaline phosphatase had higher values in the extract of the hair regrowing area compared with that in the nongrowing area. In studying the effects of various physical and chemical treatments on hair growth after shaving, repeated shaving was in itself clearly shown to stimulate hair growth. Amongst all of the treatments that were applied, topical application of TPA was most able to accelerate hair regrowth, followed by UV irradiation and retinoic acid treatment. Suppression of hair regrowth was observed in PUVA, DHT, and estradiol; and complete inhibition was seen in the animals treated with betamethasone valerate. In biochemical studies, a relatively good correlation was observed between the rate of hair regrowth and skin ODC activities after treatment.

[Combined therapy of psoralen plus ultraviolet A followed by narrow band ultraviolet B photochemotherapy for early stage mycosis fungoides]

OBJECTIVE

Only a few clinical reports in the treatment of early mycosis fungoides (MF)(IA, IB, IIA stage) are available in the literature. The purpose of this study was to compare the efficacy and safety of narrow-band UVB and psoralen plus ultraviolet A (PUVA) photochemoterapy in 24 patients with early-stage MF, and explore a new approach for the treatment of early mycosis fungoides.

METHODS

A total of 24 identified early mycosis fungoides patients received PUVA, NB-UVB and a combined therapy of PUVA followed by NB-UVB (n = 9/6/9) irradiation. A retrospective study was carried out to analyze the sex, age of onset, TNM stage, treatment, and duration of treatment, and times of treatment, duration of maintenance treatment, effective and recurrence in these patients. The data were analyzed using SPSS 17.0 and a two-sided test at the α = 0.05 level of significance was conducted.

RESULTS

Of the 24 patients studied, the average treatment was 104.5 (95% CI, 75.71-133.29) times. The average duration of treatment was 12.88 (95% CI, 9.90-15.85) months. The average maintenance treatment time was 11.08 (95% CI, 2.13-20.04) months. The effective rate (CR+PR) of PUVA treatment was 88.9%, recurrence rate was 11.1% (n = 9). In the NB-UVB treatment group, the effective rate was 100.0%, and the recurrence rate was 33.3% (n = 6). In the PUVA followed by NB-UVB (combination therapy) treatment group, the effective rate was 77.8% and the recurrence rate was 55.6% (n = 9). There were no significant differences among the three groups in terms of number of treatments, treatment duration, maintenance treatment duration, effective rate and recurrence rate (P > 0.05).

CONCLUSIONS

PUVA and NB-UVB are effective and safe in the targeted therapy of early stage mycosis fungoides. The combined therapy of PUVA followed by NB-UVB can reduce the total PUVA dose and risk of developing skin cancer.

Protective Effect of Epigallocatechin Gallate and Esculetin on Oxidative DNA Damage Induced by Psoralen Plus Ultraviolet-A Therapy

We examined antioxidants exhibiting no effects on DNA cross-linking, which is the basis of psoralen and ultraviolet-A therapy for skin diseases, and suppressing oxidative DNA damage incidental to the therapy. Epigallocatechin gallate and esculetin effectively suppressed oxidative DNA damage with little effect on the formation of DNA cross-linking. These antioxidants might be useful in suppressing the adverse reaction induced by this therapy.

Randomized controlled observer-blinded treatment of chronic foot eczema with iontophoresis and bath-PUVA

The aim of this study was to investigate the effect of iontophoresis combined with local psoralen plus ultraviolet A (PUVA) therapy in chronic foot eczema. A randomized, observer-blinded, multi-centre study was conducted in 48 patients with chronic moderate-to-severe foot eczema randomized to one of 3 groups: In the iontophoresis group local bath-PUVA was preceded by iontophoresis. In the PUVA group only local PUVA was given. The corticosteroid group was treated with fluticasone. All treatments were given for 8 weeks, with an 8-week follow-up period. The primary efficacy parameter was eczema score described by Rosén et al. Secondary efficacy parameters were a global impression by the patient, and the Dermatology Life Quality Index (DLQI). The eczema score and the DLQI decreased significantly over time. There were no significant differences in the decrease in eczema score (p=0.053) and DLQI values (p=0.563) between the 3 treatments. The DLQI values in our chronic foot eczema patients were high. There was no obvious advantage of local bath-PUVA with or with-out iontophoresis over local steroid therapy.

[Environmental UV radiation levels for dosing PUVA-sol in Mexico]

BACKGROUND

PUVA-sol therapy has the advantage of its extensive availability and low cost. However, its use is empirical. The aim was to quantify the environmental UVA radiation and suggest a method for PUVA-sol administration.

METHODS

we measured the UV radiation in the center of México (22 °N, 101 °W, 1877 m) by means of terrestrial radiometry from 2007 to 2011. We registered the variations according to hour, month, cloudiness and transmission through domestic silicate plates.

RESULTS

more than 75 % of the UVA radiation is registered between the hours of 9:00 and 17:00. The annual lowest average intensity was 20 mW/cm(2) and the highest 25.4 mW/cm(2) (ANOVA, p < 0.001). The monthly UVA irradiation during the zenith for clear skies can be estimated by the following formula: 23.8 + 0.13 (month) - 0.13 (month - 6.5)(2), (r(2) = 0.95, p < 0.001). The commonly used silicate plate (3 mm) has a UVB absorbance of 0.93, and UVA transmittance of 0.58.

CONCLUSIONS

the rational use of PUVA-sol is possible on the basis of the obtained data. It is necessary to isolate UVB radiation, and to adjust exposure during cloudy days, as well as following the safety protocol to obtain benefit and to reduce the risk of adverse effects.