Heliotherapy improves vitamin D balance and atopic dermatitis.

BACKGROUND: Vitamin D insufficiency during winter is common in the Nordic countries. Heliotherapy (HT) may heal atopic dermatitis (AD) but its effect on vitamin D balance has not been examined. OBJECTIVES: To study the effect of HT on serum calcidiol (25-hydroxyvitamin D) concentration and on healing of AD. METHODS: Twenty-three adult patients with AD received a 2-week course of HT in the Canary Islands in either January or March 2005. Daily solar ultraviolet (UV) radiation was measured and personal UV exposure calculated as standard erythema doses (SED). Blood samples were taken during HT and during a 1-2 month follow-up. Serum calcidiol concentration was measured by radioimmunoassay. Healing of AD was examined by SCORAD index. RESULTS: Before HT 17 (74%) AD patients had vitamin D insufficiency (calcidiol < 50 nmol L(-1)) and four patients high (> 80 nmol L(-1)) serum calcidiol values. The median personal UV dose during the 2-week HT course was 60 SED in the January group and 109 SED in the March group. Serum calcidiol concentration increased significantly in both groups, by 13.4 and 24.0 nmol/L(-1), respectively, and after HT only four (17%) patients had vitamin D insufficiency. SCORAD improved from 34 to 9 in the January HT group and from 30 to 9 in the March group. CONCLUSIONS: A 2-week course of HT significantly improved vitamin D balance by increasing serum calcidiol concentration, and caused a marked healing of AD. These parallel positive responses should be taken into account when the benefits of HT are considered.

Kinetics of phototoxicity in trioxysalen bath psoralen plus ultraviolet A photochemotherapy.

A trioxysalen bath is a safe alternative to systemic 8-methoxypsoralen in long-term psoralen plus ultraviolet A (PUVA) treatment. The kinetics of its main side-effect, the strong phototoxicity, has not been thoroughly studied. This study determined the degree and persistence of phototoxicity after a single 10 min bath at a trioxysalen concentration of 0.33 mg/l. The buttock skin of 16 healthy volunteers was irradiated with UVA 10 min, and 1, 3, 9 and 24h after the bath. The minimal phototoxic dose (MPD) was assessed 48, 72 and 96h after the bath. In general, the 96 h reading showed the lowest values of MPD; for example, a median of 0.14 J/cm2 (95% confidence interval 0.10-0.14 J/cm2) at sites irradiated 10 min after the bath. The values increased progressively with later irradiation, and the maximum dose applied, 18.32 J/cm2, failed to produce any redness when irradiation was given 24 h after the bath. Substantial phototoxicity persists up to at least 9h after the trioxysalen bath, making it wise for patients to avoid sunshine for at least the rest of the day.

Concentration-dependent phototoxicity in trimethylpsoralen bath psoralen ultraviolet A.

BACKGROUND: Long-term use of topical trimethylpsoralen (TMP) psoralen bath plus ultraviolet A (bath PUVA) is considered safe with regard to the risk of skin cancer. However, the potential for severe phototoxicity limits its use. OBJECTIVES: To study the effect of dilution of the TMP bath on the minimal phototoxic dose (MPD). METHODS: Fifteen volunteers participated in the study. The MPD tests were performed for three TMP concentrations: 0.33 mg L-1, 0.1 mg L-1 and 0.033 mg L-1 at 2-week intervals. Geometric UVA dose series increasing by a factor of radical2 were used for the testing on the previously unexposed buttock skin. The MPD72 h was assessed at 72 h from the bath. RESULTS: For the highest TMP concentration of 0.33 mg L-1, the median MPD72 h was 0.14 J cm-2 (95% confidence interval (CI), 0.10-0.14 J cm-2). For the diluted TMP bath concentration of 0.1 mg L-1, the median MPD72 h increased to 0.29 J cm-2 (95% CI, 0.2-0.41 J cm-2) and for 0.033 mg L-1 to 0.81 J cm-2 (95% CI, 0.57-1.15 J cm-2), respectively. Thus, diluting the labelled concentration of 0.33 mg L-1 1 : 10 increased the median MPD72 h 5.6-fold. CONCLUSIONS: With regard to the safety and practicality of the TMP bath PUVA, the lower concentrations of TMP may be of clinical importance, and this needs to be validated in future controlled clinical trials.

Cumulative UV radiation dose and outcome in clinical practice: effectiveness of trioxsalen bath PUVA with minimal UVA exposure.

BACKGROUND: The cumulative artificial ultraviolet (UV) exposure dose of dermatological patients was prospectively monitored in clinical conditions for a total of 2 years (August 1997 - July 1999). We focused on whole body UV treatments, i.e. the trioxsalen (TMP) bath PUVA, the broad-band UVB, and the UVA plus UVB phototherapy. METHODS: Irradiance of the UV devices was calibrated with a spectroradiometer. The cumulative UV doses received by the patients were recorded. A visual analog scale scoring system (VAS) was employed to assess the improvement of various skin conditions at the end of the treatment course. RESULTS: The analysis included 265 patients (141 females and 124 males) and a total of 311 UV treatment courses. Treatments consisted of 86 courses of TMP bath PUVA for psoriasis with a mean cumulative UVA dose of 3.54 J/cm2 and an improvement rate of 89%. For other conditions, 30 courses were needed, with a cumulative UVA dose of 1.47 J/cm2 and an improvement rate of 76%. Altogether, 47 UVB courses were undertaken for psoriasis, and the mean cumulative unweighted UV dose was 2.20 J/cm2, equivalent to 85 standard erythema doses (SED), and an improvement rate of 85%. A total of 25 UVB courses was used for other skin conditions with a mean UV dose of 1.05 J/ cm2, equivalent to 40 SED, and an improvement rate of 71%. A total of 123 courses of UVA plus UVB phototherapy were completed, resulting in a mean cumulative dose of 73.01 J/cm2 for UVA and 0.75 J/cm2 for the unweighted UVB, equivalent to 29 SED. The VAS improvement rate was 85%. CONCLUSION: The exceptionally low mean cumulative UVA dose in the TMP bath PUVA, taken together with the previous report showing no increase in the risk of squamous cell carcinoma or cutaneous malignant melanoma after TMP bath PUVA, suggests that TMP bath PUVA is an effective and safe therapeutic option.

Severe anaphylaxis after a chlorhexidine bath.

Anaphylaxis to chlorhexidine is rare. We report a patient who experienced anaphylaxis during a whole body bath with chlorhexidine. Early signs of a type I allergy may have been masked because of previous concomitant treatment with corticosteroids and PUVA.

Effect of heliotherapy on the cost of psoriasis.

A 2-year trial was conducted to evaluate the cost-effectiveness of heliotherapy for psoriasis. The course and cost of psoriasis of 46 Finnish patients were first closely monitored for 1 year, then the patients received a 4-week supervised heliotherapy treatment in the Canary Islands, Spain, after which they continued to be followed for another year. Heliotherapy dramatically reduced the severity of psoriasis and also seemed to have favourable long-term effects on psoriasis. The mean direct cost of the 4-week heliotherapy for one patient was FIM12,289 (1 Pound = FIM7.0 in 1989). The cost of flights and half-board in Spain formed nearly 60% (FIM7033) of the total cost. In the year preceding heliotherapy, the mean direct annual cost of antipsoriasis therapy was FIM7335 and in the year after FIM5700, a reduction of 22% in annual costs; this change was not statistically significant because there were large variations in costs among patients. The costs of heliotherapy exceeded manyfold the mean monthly cost of conventional psoriasis therapy. There were no overall savings using heliotherapy in those patients suffering mainly from moderately severe psoriasis. Heliotherapy saved costs only in those patients with severe psoriasis that required expensive medication or ward treatment. Although heliotherapy cannot be regarded as an economical treatment for the average patients with psoriasis, it clears psoriasis effectively and is preferred by patients. Thus, heliotherapy constitutes an alternative for patients suffering severe psoriasis.

Supervised four-week heliotherapy alleviates the long-term course of psoriasis.

The long-term effects of psoriasis heliotherapy were studied in a randomized cross-over trial with a 2-year follow-up. We allocated 95 patients randomly to receive a 4-week heliotherapy course, either at the onset or in the middle of the follow-up period. After a highly significant immediate alleviation of psoriasis about 50% of the patients still had a reduction of psoriasis 6 months later and about 25% one year later. A favourable carry-over treatment effect was still observed during the second follow-up year. Taking advantage of the cross-over design, the effect of heliotherapy was calculated to be statistically significant during the first follow-up year, and the apparent long-term alleviation of psoriasis after the heliotherapy was reflected in a significant period effect. The alleviation of psoriasis was accompanied by a significant decrease in the use of antipsoriatic treatments.

Effect of heliotherapy on skin and joint symptoms in psoriasis: a 6-month follow-up study.

The effect of heliotherapy on psoriasis skin lesions and arthritis was studied in a trial comprising 4 weeks of therapy in the Canary Islands and a 6-month follow-up period. A total of 373 patients participated in the heliotherapy and 361 patients completed the follow-up period. The severity of skin lesions was evaluated using a psoriasis severity index (PSI), and that of the arthropathy by using an arthritis index (AI). During heliotherapy, the PSI decreased significantly from the initial median value of 4.5 to the final value of 0.2. A reduction in the PSI of at least 75% was achieved in 84% of the patients. Guttate psoriasis improved significantly better than plaque-type or erythrodermic psoriasis. There was no correlation between skin type and improvement. Initially, 129 patients had symptoms of arthritis. During heliotherapy, the AI decreased significantly from the initial median value of 6 to the final value of 2. The median time until starting another treatment after heliotherapy was 80 days, and the PSI had returned to its original value in 49% of the patients in 6 months. In patients with joint symptoms the AI returned to the pretreatment level within 6 months. A 4-week heliotherapy period effectively cleared psoriasis, alleviated joint symptoms, and reduced both morbidity and treatment requirement to a considerable extent in the ensuing 6-month period.

Comparison of the antipsoriatic efficacy of heliotherapy and ultraviolet B: a cross-over study.

Ten psoriasis patients who underwent a 4-week heliotherapy period in the Canary Islands were treated with ultraviolet B (UVB) phototherapy at relapse, 2-24 months later. In both settings, psoriasis improvement was monitored using a psoriasis severity index (PSI), and UV exposure was recorded with polysulphone films. In the 8 patients that could be evaluated, a median healing rate of 94% was recorded in the heliotherapy period, with a median cumulative UV dose of 46 erythemal units (EU). In the UVB phototherapy, a median improvement rate of 86% was found after a median cumulative UV dose of 112 EU. It is concluded that, on an erythemal UV dose basis, heliotherapy was more effective than UVB phototherapy in treating psoriasis.

Solar ultraviolet (UV) radiation and UV doses received by patients during four-week climate therapy periods in the Canary Islands.

The ultraviolet (UV) radiation doses received by 270 psoriasis patients were studied during 4-week climate therapy periods in November, March or April in the Canary Islands. The daily total solar UV radiation (ambient radiation load, ARL) was measured using frequent readings with a Robertson-Berger sunburning ultraviolet (SUV) meter. A daily personal radiation load (PRL) was calculated for each patient, using sun exposure diary data. To measure the cumulative UV exposure of particular skin sites (skin site dose, SSD), 10 patients wore polysulphone UV dosimeters. The daily ambient radiation load (ARL) ranged from 2.9 to 8.9 erythemal units (EU); the cumulative ARL for a 4-week treatment period was 182.6 EU. The mean daily personal radiation load (PRL), calculated separately for each week of the treatment period, was from 2.5 to 5.6 EU; the mean total 4-week PRL was 118.0 EU, being about 65% of the ARL. The 4-week cumulative skin site dose (SSD) varied between 22.2 and 63.3% (mean 41.2%) of the corresponding personal radiation load (PRL).

Effect of psoriasis heliotherapy on epidermal urocanic acid isomer concentrations.

A noninvasive Finn Chamber sampling method and HPLC analysis were used to determine epidermal urocanic acid (UCA) concentrations of psoriasis patients during 4 weeks of heliotherapy on the Spanish Canary Islands and a follow-up period of 8 weeks. During heliotherapy the epidermal cis-UCA concentration increased from a mean initial value of 0.2 nmol/cm2 to a mean final value of 2.9 nmol/cm2. The total UCA concentration decreased during the first week of heliotherapy from an initial value of 5.5 nmol/cm2 to a nadir of 2.0 nmol/cm2. Thereafter, a steady increase was recorded in the total UCA level, with a maximum of 10.2 nmol/cm2 in week 2 of the post-treatment follow-up period. Suberythemal sun exposures caused near-maximal UCA isomerization, and during heliotherapy the cis isomer constituted 63.7-74.3% of the total UCA concentration. Clinical response of psoriasis to heliotherapy, however, seemed to be independent of UCA isomer levels.