Phototherapy and photochemotherapy for psoriasis.

Phototherapy is a first-line option for the treatment of moderate to severe psoriasis. Systematic reviews indicate near comparable efficacy of the different forms of phototherapy. Localized phototherapy can be an adjunctive treatment of recalcitrant plaques during systemic treatment of psoriasis. More than 200 psoralen-UV-A therapy treatment sessions is associated with an increased risk of keratinocytic cancers, whereas no increased risk has been demonstrated for narrow-band UV-B therapy. The mechanism of action of phototherapy in psoriasis is via inhibition of keratinocyte proliferation; induction of apoptosis in keratinocytes, dendritic, and T cells; and inhibition of Th1 and Th17 pathways, but activation of Th2.

Comparison of clinical and cost-effectiveness of psoralen + ultraviolet A versus psoralen + sunlight in the treatment of chronic plaque psoriasis in a developing economy.

Psoralen + ultraviolet A (PUVA) therapy is an established modality for psoriasis. As India is a tropical country that has good availability of natural sunlight psoralen + sunlight (PUVAsol) may be a more convenient option. To compare the efficacy and cost-effectiveness of PUVA versus PUVAsol in chronic plaque psoriasis. Cases of chronic plaque psoriasis with body surface area ≥10% or Psoriasis Area and Severity Index (PASI) ≥10, excluding erythrodermic or pustular psoriasis, were randomized to receive either PUVA or PUVAsol, with endpoint being the achievement of PASI 90 or completion of 12 weeks treatment, whichever is earlier. Cost analysis was also undertaken. Thirty-six cases (16 in PUVA and 20 in PUVAsol group) completed treatment. In the PUVA group, 15 cases (93.75%) responded to therapy while in the PUVAsol group, 15 (75%) responded (P = 0.29). Mean baseline PASI in the PUVA and PUVAsol groups was 16 and 14.4, respectively, and at endpoint was 1.62 and 3.77. There was a significantly greater reduction in PASI in the PUVA group at 2 and 4 weeks but at 8 and 12 weeks and endpoint, it was comparable. Treatment failure occurred in 6.25% and 25% of cases respectively (P = 0.29). Side effects were higher with PUVA. Total cost of therapy was significantly higher in the PUVA group (P = 0.002). Cost-effectiveness ratio was US$0.72 with PUVA and US$0.37 with PUVAsol. Both PUVA and PUVAsol were equally efficacious, with PUVAsol being twice as cost effective. Hence, PUVAsol may be recommended as treatment for psoriasis in a developing economy such as India.

Patient-reported reasons for the discontinuation of commonly used treatments for moderate to severe psoriasis.

BACKGROUND: Despite widespread dissatisfaction and low treatment persistence in moderate to severe psoriasis, patients' reasons behind treatment discontinuation remain poorly understood. OBJECTIVES: We sought to characterize patient-reported reasons for discontinuing commonly used treatments for moderate to severe psoriasis in real-world clinical practice. METHODS: A total of 1095 patients with moderate to severe plaque psoriasis from 10 dermatology practices who received systemic treatments completed a structured interview. Eleven reasons for treatment discontinuation were assessed for all past treatments. RESULTS: A total of 2231 past treatments were reported. Median treatment duration varied by treatment, ranging from 6.0 to 20.5 months (P < .001). The frequency of each cited discontinuation reasons differed by treatment (all P < .01). Patients who received etanercept (odds ratio [OR] 5.19; 95% confidence interval [CI] 3.23-8.33) and adalimumab (OR 2.10; 95% CI 1.20-3.67) were more likely to cite a loss of efficacy than those who received methotrexate. Patients who received etanercept (OR 0.34; 95% CI 0.23-0.49), adalimumab (OR 0.48; 95% CI 0.30-0.75), and ultraviolet B phototherapy (OR 0.21; 95% CI 0.14-0.31) were less likely to cite side effects than those who received methotrexate, whereas those who received acitretin (OR 1.56; 95% CI 1.08-2.25) were more likely to do so. Patients who underwent ultraviolet B phototherapy were more likely to cite an inability to afford treatment (OR 7.03; 95% CI 3.14-15.72). LIMITATIONS: The study is limited by its reliance on patient recall. CONCLUSIONS: Different patterns of treatment discontinuation reasons are important to consider when developing public policy and evidence-based treatment approaches to improve successful long-term psoriasis control.

Review of home phototherapy.

BACKGROUND: Outpatient phototherapy is a safe, effective, and low-cost treatment modality for moderate to severe psoriasis. Barriers to outpatient phototherapy including patient inconvenience, patient co-pays, decreased physician compensation, and insurance disincentive structures have led to decreased use and underutilization of phototherapy. Home phototherapy can potentially overcome many of the barriers associated with outpatient treatment but is not widely used because of concerns over safety and efficacy, lack of resident and physician education, and lack of insurance coverage. PURPOSE: The purpose of this study is to review the use of phototherapy with emphasis on the safety, efficacy, and practical use of home phototherapy. METHODS: A comprehensive Pubmed literature search was done using the keywords NB-UVB, narrowband UVB, BB-UVB, broadband UVB, PUVA, psoralen and UVA, UVA, history of phototherapy, mechanism of phototherapy, phototherapy in dermatology, home phototherapy, and phototherapy for psoriasis. All relevant articles were reviewed. CONCLUSIONS: Home NB-UVB phototherapy can be as safe, effective, and cost-effective as outpatient phototherapy. Further, home UVB is more convenient for patients, has higher patient satisfaction, and a lower treatment burden compared to outpatient phototherapy. Home NB-UVB should be considered as a treatment option for patients eligible for phototherapy.

Patients with moderate-to-severe plaque psoriasis preferred oral therapies to phototherapies: a preference assessment based on clinical scenarios with trade-off questions.

OBJECTIVE: The importance of validly identifying and incorporating patients' views for improving health care is generally acknowledged. Common approaches to assess patients' preferences are based on the quality adjusted life year (QALY) framework, but this ignores a number of aspects that may be relevant. As an alternative, we assessed patients' treatment preferences and trade-offs for five common systemic therapies for psoriasis. STUDY DESIGN AND SETTING: Twenty-nine patients with moderate-to-severe psoriasis expressed treatment preferences for five oral and phototherapies and indicated the relative importance of various treatment attributes, such as adverse effects, discomforts, and safety measures. In a structured interview, they were presented with clinical scenarios that contained descriptions of process and outcome characteristics and illustrations of the anticipated treatment benefit. RESULTS: Over all paired comparisons, methotrexate (33%), cyclosporin (30%), acitretin (15%), UV-B (14%), and PUVA (8%) were preferred to the other treatment. Patients were willing to trade-off their initial preference for more improvement of psoriasis. CONCLUSIONS: Psoriasis patients generally prefer oral to phototherapies and consider most adverse effects and several discomforts important for selecting treatment. Our scenario-based structured interview approach to treatment preferences allowed us to incorporate a broad spectrum of potentially relevant decision components in a clinically meaningful way.

Psoriasis y enfermedades afines: experiencia con Re-PUVA en el manejo de psoriasis moderada-severa / Psoriasis and related diseases: experience with Re-PUVA in the treatment of moderate-to-severe psoriasis

Introducción: El manejo de la psoriasis moderada-severa es complejo, y un importante número de pacientes considera que el tratamiento indicado por su médico tratante no es suficientemente agresivo. El uso de tratamientos combinados ha demostrado mayor efectividad que las monoterapias, logrando aclaración de las lesiones en menor tiempo, con dosis más bajas de agentes terapéuticos y menos efectos adversos. Objetivos: Presentar nuestra experiencia con terapia combinada de retinoides más PUVA (Re-PUVA) en pacientes con psoriasis moderada-severa. Pacientes y Métodos: Se trató a nueve pacientes con psoriasis moderada-severa, mayores de 18 años, con terapia combinada de acitretín+PUVA, evaluando respuesta clínica bajo protocolo y seguimiento fotográfico al inicio 8ª y 16ª semana de tratamiento. Se estimaron dosis requeridas, costos, y efectos adversos del tratamiento. Resultados: El tiempo de tratamiento requerido para conseguir aclaración en el 90 por ciento de los pacientes fue de siete semanas. La dosis promedio de acitretín fue de 033 mg/kg/ día y la dosis acumulada de UVA fue de 139 J/cm². El costo estimado para conseguir aclaramiento en el 90 por ciento de los pacientes fue de US$ 634. No se observaron efectos adversos severos. Conclusión: La terapia combinada Re-PUVA demostró ser una excelente opción terapéutica para psoriasis moderada-severa, lográndose óptimos resultados en un corto plazo, a un costo razonable, y sin efectos adversos severos.

Traditional therapies in the management of moderate to severe chronic plaque psoriasis: an assessment of the benefits and risks.

Psoriasis is a chronic, recurrent disease that affects between 1% and 3% of the population. Patients with moderate to severe disease generally require phototherapy (e.g. narrowband ultraviolet B radiation), photochemotherapy (oral psoralen plus ultraviolet A radiation) or systemic agents (e.g. ciclosporin, methotrexate, oral retinoids, fumaric acid esters) to control their disease adequately. In general, these therapeutic modalities have proven to be highly effective in the treatment of psoriasis. However, potentially serious toxicities can limit their long-term use. Given that there is no standard therapeutic approach for patients with moderate to severe psoriasis, the benefits and risks of phototherapy, photochemotherapy and systemic therapy must be weighed carefully for each patient, and treatment individualized accordingly. This review summarizes the benefits and risks of traditional, nonbiological therapies for moderate to severe chronic plaque psoriasis.

Strategy to manage the treatment of severe psoriasis: considerations of efficacy, safety and cost.

Psoriasis is a common, unpredictable, chronic immune-mediated disease characterised by skin lesions and frequently associated with arthritis. Although rarely fatal, psoriasis has a tremendous impact on a patients' quality of life. Traditional therapies for severe psoriasis include phototherapy, methotrexate, oral retinoids and cyclosporin. New biological agents add to the treatment options for psoriasis; however, they raise the already considerable cost of managing the disease. In considering efficacy, safety and cost-effectiveness, ultraviolet Type B (UVB) phototherapy appears to be the best first-line agent for the control of psoriasis. Methotrexate, psoralen plus UVA, alefacept, etanercept and infliximab are appropriate second-line agents, the choice of which requires considerable patient input and physician judgement. Developing rational, effective and acceptable strategies to manage psoriasis treatments would encourage cost-effective psoriasis management.

Objective assessment of photoageing effects using high-frequency ultrasound in PUVA-treated psoriasis patients.

BACKGROUND: Skin ageing can be differentiated into intrinsic (chronological) ageing, and photoageing due to chronic sun exposure. Photoageing is the superimposition of photodamage on the ageing process. OBJECTIVES: The aim of the study was to investigate possible differences between the skin of photochemotherapy (PUVA)-treated psoriasis patients and of untreated normal subjects using a high-frequency ultrasound system. METHODS: A total of 124 volunteers (aged 21-88 years, median 52 years, 62 female, 62 male), 62 psoriasis patients who had received PUVA therapy and 62 healthy controls, were investigated. Skin thickness and a subepidermal low-echogenic band (SLEB), a parameter for photodamage, were measured in 12 different areas. RESULTS: Female skin is thinner than male skin. The skin thickness values of PUVA patients were more markedly decreased than those of the controls for the older patients. There was a clear dependence of the occurrence of SLEB on PUVA therapy in psoriasis patients. CONCLUSIONS: Long-term PUVA treatment in psoriasis patients accelerates thinning of the skin in comparison to age-matched controls. The results show that ultrasonography is a sensitive method to investigate the effects of PUVA-induced skin ageing.

[The UV record. Document for quality control, therapy planning and risk assessment in dermatologic photo- and photochemotherapy]. / Der UV-Pass. Instrument der Qualitätskontrolle, Therapieplanung und Risikoabschätzung bei dermatologischer Photo- und Photochemotherapie.

Ultraviolet (UV-) radiation therapy as a mono- or combination therapy (UV-A, UV-A1, UV-B, SUP, UV-B311) or as photochemotherapy with photosensitization (systemic PUVA-, bath PUVA-, topical PUVA-therapy) are successfully used for the treatment of several dermatological disorders. Long-term side effects of natural UV (sun light) include photoaging and induction of skin tumors. At present, the relevance of in-vitro findings of potential tumor induction in animals through therapeutic levels of UV radiation is a matter of debate. To assess these risks, information on treated location, kind of UV radiation and cumulative UV doses are required. Practically this information is barely accessible. This makes decisions on possible therapies difficult. To solve this problem we propose to use an "UV pass". At the end of each UV radiation cycle, the body location, the type of radiation and the cumulative dose are documented and this pass is given to the patient. This will improve the information transfer if the doctor is changed, as well as facilitating decisions about certain therapies and calculation of long-term risks of UV radiation. Finally it will improve the quality of UV photo- and photochemotherapy.

Do tanning lamps cause melanoma? An epidemiologic assessment.

Sun exposure is a known cause of melanoma, and there are several reasons for concern that tanning lamp use may also cause melanoma, especially because of the spectral output of the lamps,the similarity of tanning lamp use to natural sun exposure (particularly sunbathing), the reported association of melanoma with PUVA therapy, and the positive results in several case-control studies of melanoma risk and tanning lamp use. We have reviewed the epidemiologic literature relevant to the relation between tanning lamp use and melanoma and have discussed methodologic issues that should be considered in interpreting these reports and designing improved studies. Although several investigations have found a positive relation between tanning lamp use and melanoma, in some instances including dose-response or duration-response effects, the methodologic limitations preclude any firm conclusion regarding a causative relation. Meta-analysis of existing data may provide better information, but several limitations could only be overcome by new studies collecting more precise exposure data. The popularity of tanning lamp use, especially in young persons, adds urgency to the quest for elucidation of the relation between the use of these devices and melanoma risk.

Modifications of PUVA.

The goal of photochemotherapy in psoriasis is to attempt to lower the number of exposures and the total cumulative doses while still maintaining good control of the disease. PUVA has been modified by using better psoralen preparations and more effective light sources, and it also has been combined with other treatment modalities. The objectives in modifying PUVA and combining PUVA with other treatment modalities are to increase efficacy, to reduce short- and long-term adverse effects, and to reduce the cost of treatment. Modalities that have been combined with PUVA include topical corticosteroids, anthralin, calcipotriene ointment, methotrexate, UVB, retinoids, and cyclosporine.

PUVA: how to use it for maintenance.

The selection of optimal maintenance therapy for psoriasis needs great dermatologic skill. The choice between topical therapy, photochemotherapy (PUVA), UVB, and immunomodulating regimens alone or in combinations is a balance between cost and benefit. The effectiveness of healing and the tendency to relapse stands against convenience and access of therapy, the patients' motivation, and not least, the risks of side effects. The effective PUVA-maintenance must be reserved for patients who do not experience clearing of their disease on mild topical and UVB regimens.

Position paper--PUVA therapy. American Academy of Dermatology.

PUVA, the combination of psoralen (P) and long-wave ultraviolet radiation (UVA), is being used increasingly in the management of psoriasis and several other dermatologic disorders. While the acute toxicity of this modality, which includes erythema and blistering of the skin, can be avoided with careful monitoring of the dosimetry of the administered radiation, the potential chronic toxicity remains a source of concern. Since psoralens and UVA are clearly mutagenic, carcinogenic, cataractogenic, and may have as yet poorly understood effects on the immune system, it is imperative that all patients treated with this modality be carefully monitored for the development of neoplasia and cataracts. PUVA therapy should only be administered using specialized equipment that can be accurately monitored for its spectral irradiance by physicians thoroughly familiar with the risks and benefits of the modality.