Serum 25-hydroxyvitamin D levels in patients with atopic eczema and the influence of narrowband ultraviolet B phototherapy.

BACKGROUND: Narrowband ultraviolet B phototherapy (nbUVB) is an established treatment modality for patients with severe atopic dermatitis (AD) and is known to increase serum vitamin D levels (SVD). The relationship between SVD and AD remains unclear. OBJECTIVES: To assess SVD and disease severity in patients with AD before and after nbUVB and establish whether a change in SVD correlates to response to nbUVB. Methods: A single-centre, open observational study recruited 21 male and 17 female patients with AD between November and April. Eczema severity was measured using the SCORAD tool, and serum 25-hydroxyvitamin D3 levels were determined before and after nbUVB, which was administered thrice weekly. RESULTS: Nine patients had severe AD, 23 moderate and six mild, as indicated by SCORAD measurements. Seventeen patients completed the study. Median SVD increased from 45 nmol/l pre-treatment to 169 nmol/l post-treatment (95% CI 2.9­5.0 times baseline) (P < 0.0001). Mean SCORAD reduction following nbUVB was significant at 21.9 units (95% CI, 14.9­28.9) (P < 0.0001). No evidence of a relationship between change in SCORAD and change in SVD was found. LIMITATIONS: A significant number of patients failed to complete the study. CONCLUSIONS: Patients with AD are at risk of vitamin D deficiency. Correlation between this and disease severity has been postulated, but this study does not provide confirmatory evidence.

Psoralen and ultraviolet A in the treatment of granuloma annulare.

BACKGROUND: Granuloma annulare (GA) is a benign, usually self-limiting disease. Lesions may be localized or generalized with a tendency for generalized disease to follow a chronic course. There is evidence to support psoralen and ultraviolet A (PUVA) in the treatment of GA, but little data on long-term benefits. The purpose of this study was to investigate the effect of PUVA in the treatment of GA, and to establish clearance and remission rates. METHODS: We carried out a retrospective study of patients with generalized GA treated with PUVA over 13 years. Data were collected from case notes and a phototherapy database. On completion of treatment, outcome was assessed as clear, good improvement, moderate improvement and poor outcome. Follow-up data were obtained for patients who had cleared using a postal questionnaire in addition to clinic notes. RESULTS: Fifty per cent of courses resulted in clearance of disease, 16% in good improvement, 25% had moderate benefit and 9% had a poor outcome. Of the patients that cleared, 79% remained in remission at 6 months but only 32% were still clear 12 months following treatment. CONCLUSION: Our findings show clearance or good improvement of generalized GA in 66% of cases. Prolonged remission, however, occurred in less than a third of patients.

Narrowband ultraviolet B phototherapy does not influence serum and red cell folate levels in patients with psoriasis.

BACKGROUND: Narrowband ultraviolet (UV) B phototherapy (nbUVB) is a widely used modality in the treatment of psoriasis and is generally accepted to be safe in pregnancy. Previous studies have described photodegradation of serum folate after exposure to UVA radiation but the effect of UVB is not known. Insufficient folate levels predispose to neural tube defects in pregnancy. In addition, folate deficiency may increase the risk of colorectal carcinoma and influence serum homocysteine levels, which are thought to be a risk factor for cardiovascular disease. OBJECTIVE: We sought to determine whether exposure to nbUVB reduces folate levels. METHODS: This single-center, open observational study was conducted in a teaching hospital setting. Serum and red cell folate levels were measured in patients with psoriasis attending for nbUVB at baseline and after a minimum of 18 exposures. RESULTS: A total of 35 patients completed the study. Mean serum and red cell folate levels at baseline were 6.34 and 410 ng/ml, respectively. After nbUVB, mean serum and red cell folate levels were 6.35 and 423 ng/ml, respectively. This was not significantly different from baseline measurements (P = .99 serum folate and P = .57 red cell folate). LIMITATIONS: This study examined the effect of a standard course of 18 exposures of nbUVB on folate levels, rather than prolonged treatment. Adult patients with psoriasis only were investigated. CONCLUSION: A standard course of nbUVB does not have an effect on serum and red cell folate levels in patients with psoriasis.

Low-dose UVA1 phototherapy for proximal and acral scleroderma in systemic sclerosis.

Previous studies report the benefit of UVA1 phototherapy in treating acrosclerosis in patients with systemic sclerosis. We carried out a retrospective study to examine the effectiveness of UVA1 phototherapy in scleroderma affecting acral and proximal sites in patients with this disease. Patients with systemic sclerosis (diffuse type, n=5; limited type, n=3) underwent low-dose UVA1 radiation (30-40 J/cm(2)) thrice weekly. In all patients skin lesions improved, demonstrated by a fall in the modified Rodnan skin score ranging from 8 to 18 points in diffuse systemic sclerosis and 6 to 10 points in limited disease. This study would suggest that UVA1 phototherapy is effective for scleroderma affecting proximal and acral sites in patients with systemic sclerosis.

The spontaneous resolution of photosensitivity and contact allergy in a patient with chronic actinic dermatitis.

Chronic actinic dermatitis (CAD) is an uncommon photodermatosis in which patients typically exhibit photosensitivity together with contact allergy. Improvement of the photosensitivity over time is well recognized in a proportion of patients but the concurrent resolution of contact allergy is rare. We report on a 46-year-old female with longstanding CAD who demonstrated resolution of both of these features.

Five-year follow-up of a randomized, prospective trial of topical methyl aminolevulinate photodynamic therapy vs surgery for nodular basal cell carcinoma.

OBJECTIVE: To compare 5-year lesion recurrence rates in primary nodular basal cell carcinoma treated with topical methyl aminolevulinate photodynamic therapy (PDT) or simple excision surgery. DESIGN: Prospective, randomized, multicenter study. SETTING: University hospital dermatology departments. PATIENTS: A total of 97 patients, 50 with 53 lesions treated with methyl aminolevulinate PDT and 47 with 52 lesions treated by excision surgery, were included in the per protocol analysis. Of the lesions treated with methyl aminolevulinate PDT and surgery, 49 and 52, respectively, showed complete clinical response at 3 months after treatment and were observed for long-term outcome evaluation. INTERVENTIONS: Topical methyl aminolevulinate cream, 160 mg/g, applied for 3 hours before illumination (75 J/cm(2) of red light at 570 to 670 nm) on 2 or 4 occasions (12 [23%] of 53 lesions); or excision surgery. MAIN OUTCOME MEASURES: Histologically confirmed lesion recurrence, sustained lesion complete response rate (time-to-event analysis), and investigator assessment of cosmetic outcome, 5 years after the last treatment. RESULTS: At 5 years, recurrence was documented in 7 (14%) of 49 lesions (95% confidence interval [CI], 6%-27%) treated with methyl aminolevulinate PDT vs 2 (4%) of 52 lesions (95% CI, 1%-13%) treated with excision surgery (P = .09). Estimated sustained lesion complete response rates were 76% (95% CI, 59%-87%) and 96% (95% CI, 84%-99%), respectively (P = .01). More patients treated with methyl aminolevulinate PDT than surgery had an excellent or good cosmetic outcome: 27 (87%) of 31 patients (95% CI, 70%-96%) vs 19 (54%) of 35 patients (95% CI, 37%-71%) (P = .007). CONCLUSIONS: Long-term follow-up indicates superior efficacy of surgery to methyl aminolevulinate PDT in nodular basal cell carcinoma. However, methyl aminolevulinate PDT is also an effective treatment for this indication and exhibits a more favorable cosmetic outcome.

Use of complementary medicine among outpatients with dermatologic conditions within Yorkshire and South Wales, United Kingdom.

BACKGROUND: The use of complementary and alternative medicine (CAM) is increasing throughout the Western world, particularly by patients with chronic disease. In 1999, 20% of the United Kingdom population reported that they had used CAM in the preceding 12 months. OBJECTIVES: We sought to investigate the use of CAM by outpatients with general dermatologic conditions in 3 United Kingdom cities: Leeds (North England), and Cardiff and Swansea (South Wales). METHODS: Independently constructed, anonymous, self-directed questionnaires were designed and distributed to 400 consecutive outpatients with dermatologic conditions in Leeds and 637 consecutive outpatients with dermatologic conditions in Cardiff and Swansea. RESULTS: In Leeds 302/400 questionnaires were fully completed with 39% patients having used CAM. In South Wales 415/637 questionnaires were fully completed with 34% having used CAM. Of these, 45% of patients in Leeds and 50% of patients in South Wales were using CAM to treat their dermatologic condition. The most popular treatments in Leeds, Cardiff, and Swansea were herbal medicine and homeopathy. LIMITATIONS: These results were obtained from outpatients with dermatologic conditions in the United Kingdom and may not be applicable to other populations. CONCLUSIONS: More than one third of outpatients with general dermatologic conditions in two geographically distant regions are using CAM. More than 45% of these patients used CAM to treat their dermatologic condition.

Photodynamic therapy using topical methyl aminolevulinate vs surgery for nodular basal cell carcinoma: results of a multicenter randomized prospective trial.

BACKGROUND: Photodynamic therapy (PDT) is increasingly used as a noninvasive treatment for nodular basal cell carcinoma (BCC), without a sound evidence base. OBJECTIVE: To compare topical PDT, with the use of the sensitizer methyl aminolevulinate, and standard excision surgery in nodular BCC. DESIGN: Prospective, randomized study. SETTING: University dermatology departments. PATIENTS: A total of 101 adults with previously untreated nodular BCC. INTERVENTIONS: Patients received methyl aminolevulinate PDT (n = 52) or surgery (n = 49). The PDT was given twice, 7 days apart, with methyl aminolevulinate cream (160 mg/g) and 75 J/cm(2) red light (570-670 nm). Thirteen patients with a noncomplete response to PDT at 3 months (24% lesions) were retreated. OUTCOME MEASURES: Primary end point was clinically assessed lesion clearance at 3 months after treatment. Secondary end points were sustained response rate at 12 months and cosmetic outcome at 3 and 12 months. Cosmesis and lesion recurrence were further assessed at 24 months. RESULTS: Data from 97 patients (105 lesions) were included in the 3-month per-protocol analysis. Complete response rates did not differ significantly between groups (51/52 [98%] lesions with surgery vs 48/53 [91%] lesions with methyl aminolevulinate PDT; difference [95% confidence interval], 4.8% (-3.4% to 13.0%]; P =.25). At 12 months, tumor-free rates were 50 (96%) of 52 lesions with surgery vs 44 (83%) of 53 with methyl aminolevulinate PDT (P =.15). More patients treated with methyl aminolevulinate PDT than surgery had an excellent or good cosmetic outcome at all time points (significant at 12 and 24 months on patient assessment, P<.05, and at 3, 12, and 24 months on investigator evaluation, P<.001). At 24 months, 5 lesions that had initially cleared with methyl aminolevulinate PDT had recurred, compared with 1 after surgery. CONCLUSIONS: Methyl aminolevulinate PDT is an effective treatment for nodular BCC, and while there is a trend for higher recurrence with this modality, it conveys the advantage over surgery of better cosmesis.

Guidelines for the management of acne vulgaris in adolescents.

This article reviews the treatment of acne in adolescents. The choice of therapy should be principally based on the type of lesion and the severity of the acne, but psychosocial disability relating to the disease and the presence of scarring may also influence the approach to treatment.Mild acne generally requires topical treatment only. Benzoyl peroxide, azelaic acid, and antibacterials are generally used for inflammatory lesions. Topical retinoids are particularly effective for noninflamed lesions, and combination therapies are useful for mixed lesions. Moderately severe acne generally requires oral antibacterials. Tetracyclines/oxytetracycline and erythromycin are usually the first-line antibacterials. Second-generation tetracyclines, such as lymecycline, doxycycline, and minocycline, show improved absorption. Minocycline has the advantage of being rarely associated with Propionibacterium acnes antibacterial resistance, but can occasionally lead to potentially serious adverse effects. Trimethoprim is a useful third-line antibacterial therapy for patients resistant to other antibacterial therapies. Benzoyl peroxide should generally be used in combination with oral antibacterials as this has been shown to reduce the development of antibacterial resistance. For severe nodular acne, isotretinoin is the treatment of choice. In addition, over recent years dermatologists have increasingly used this drug to treat patients with moderate acne which has not responded to other systemic therapies, particularly when associated with scarring or significant psychological disability. However, this use is outside the current license of the drug. Isotretinoin is associated with a number of serious adverse effects and careful monitoring of patients during therapy is required.Physical therapies for the treatment of acne nodules and macrocomedones are also important adjuncts to drug therapies.