Clinical, pathological and immunohistochemical effects of arsenical-ferruginous spa waters on mild-to-moderate psoriatic lesions: a randomized placebo-controlled study.

Thermalism and spa treatments are traditionally considered effective in a number of dermatologic inflammatory conditions, yet there is scarce evidence about spring water effectiveness on psoriasis in a daily setting. We enrolled 34 patients with mild-to-moderate psoriasis in a double-blind, randomized, placebo-contralaterally-controlled trial, to evaluate Levico and Vetriolo arsenical-ferruginous water effectiveness on psoriatic lesions by daily 20-minute wet packing for 12 consecutive days. Clinical, histopathologic and immunohistochemical parameters were considered. A statistically significant difference between spa water-treated lesions and placebo-treated lesions in the same patients was demonstrated for histopathologic and immunohistochemical parameters. Since iron ions have an antiproliferative effect on epithelia, and magnesium ions have an anti-inflammatory effect, Levico and Vetriolo water effectiveness on psoriasis could be addressed to their content of these ions.

Indolent systemic mastocytosis treated with narrow-band UVB phototherapy: study of five cases.

BACKGROUND: Mastocytoses represent a heterogeneous group of stem cell disorders marked by an abnormal hyperplasia and accumulation of mast cells in one or more tissues, including bone marrow, gastrointestinal tract, liver, spleen, lymph nodes and skin. Indolent systemic mastocytosis (ISM) is characterized by red-brownish and pruriginous maculopapular lesions, a bone marrow infiltration without functional impairment and an indolent clinical course with a good prognosis. In particular, the most common cutaneous symptoms are urticarial rash and mild-to-high pruritus. OBJECTIVES: This study analyses the clinical outcome of patients affected by ISM with prevalent pruriginous cutaneous symptoms and a scarce response to anti-histamines treated using narrowband ultraviolet B (NB-UVB) phototherapy. METHODS: Narrowband ultraviolet B phototherapy was administered in a UV-irradiation cabin equipped with fluorescent UVB lamps with a peak emission at 311-313 nm. The perception of pruritus severity was assessed using the Visual Analogue Scale (VAS) before starting the treatment and at each control. RESULTS: A complete remission of the cutaneous lesions and pruritus was documented in all patients after a median of 40.3 UV treatments and a median cumulative dose of 51.4 J/cm(2), with a lasting remission over a 6-month follow-up. The median VAS score at the beginning of the treatment was 86.6 (SD=6.64), whereas it decreased to 6.66 (SD=3.75) after 3 months of therapy. CONCLUSIONS: Our work provides evidence that NB-UVB phototherapy is useful for the treatment of the cutaneous symptoms and pruritus in ISM.

Narrowband ultraviolet B phototherapy in the treatment of cutaneous graft-versus-host disease in oncohaematological paediatric patients.

BACKGROUND: Graft-versus-host disease (GVHD) represents an important complication following allogeneic bone marrow transplantation. In recent years, narrowband ultraviolet B (NB-UVB, 311-313 nm) has been found to be a beneficial adjuvant treatment in patients refractory to first-line immunosuppressive drugs. OBJECTIVES: The aim of this study is to analyse retrospectively the clinical outcome of 10 GVHD paediatric patients treated with NB-UVB therapy. PATIENTS AND METHODS: Ten paediatric patients (six girls and four boys: median age 12.5 years, range 4-20) with cutaneous GVHD were enrolled in the study: five patients with chronic GVHD and five patients with an overlap syndrome GVHD. All patients had already been shown to be resistant to first-choice immunosuppressive protocols, and were treated with NB-UVB phototherapy until a clinical remission of skin lesions occurred. RESULTS: A complete response (absence of lesions) was achieved in 80% of the cases (eight patients) after a median number of 29 treatments, corresponding to a median of 7.5 weeks (52 days) of treatment (range 3-13 weeks), with an average cumulative dose of 28.71 J cm(-2) (range 1.02-70.38 J cm(-2)). Only two patients reported a partial remission (< 18% of body surface area involved). During the follow-up period, a complete remission after 1 year was observed in 75% of patients and after 2 years in 71% of the evaluable patients. CONCLUSIONS: This study provides evidence that NB-UVB phototherapy represents a valid second-line treatment in paediatric patients affected by GVHD and refractory to immunosuppressive first-line treatment.

The duration of clinical remission of photochemotherapy and narrow-band UV-B phototherapy in the treatment of psoriasis: a retrospective study.

PUVA and UVB-NB phototherapy have an established role in the treatment of moderate-to-severe psoriasis. Even though psoriasis patients often require continuous treatments, inadequate attention is devoted to the duration of remission after the treatment. The purpose of this retrospective study is to assess which phototherapeutic regimen induces a longer remission. Twenty patients with psoriasis were included: 10 patients received PUVA and 10 patients received UVB-NB. We consider as a cycle the therapeutic period needed to reach clinical remission. The comparison between the average number of days in remission revealed that PUVA induces a longer remission period than UVB-NB: PUVA 386 days (ds +/- 321), UVB-NB 298 days (ds +/- 257). Although the difference of the duration of remission is not statistically significant, a trend is seen and patients treated with PUVA remain clear for a period about 88 days longer than that of patients treated with UVB-NB. The differences in the duration of remission of psoriasis therapies must be considered in planning a patients course of treatment.

Critical evaluation of the variants influencing the clinical response of vitiligo: study of 60 cases treated with ultraviolet B narrow-band phototherapy.

BACKGROUND: The treatment of vitiligo is still a challenge, but ultraviolet B narrow-band (UVB-NB) therapy has been recently reported to be an effective and safe therapeutic option in patients with vitiligo. OBJECTIVE: The purpose of this study is a critical evaluation of the variants (body sites, age, duration of the disease, and duration of the therapy) influencing the clinical response to UVB-NB therapy. METHODS: Sixty patients (23 male and 37 female), aged 6 to 70 years, with vitiligo, were treated with UVB-NB therapy over a maximum period of 2 years. The evaluation of the percentage of repigmentation was done through photographs. RESULTS: The lesions located on the face obtained a complete repigmentation in 68% of the patients, on the neck in 57.89%, and on the trunk in 50% within the first year of the therapy. In young patients vs. adults patients, the lesions located on the neck obtained a complete repigmentation in 83.33% vs. 46.15%, on the upper limbs in 28.57% vs. 9.52%, and on the lower limbs in 25% vs. 16.67%. In patients with vitiligo of recent onset, the lesions located on the neck obtained a complete repigmentation in 83.33%, on the upper limbs in 33.33%, and on the lower limbs in 28.57%. Hands did not give a positive response in either groups. CONCLUSION: This study shows that certain body sites respond better than others to the UVB-NB therapy; patients, aged less than 20 years, with recent vitiligo, achieve more repigmentation; the duration of the therapy can influence the response of the lesions over hands and lower limbs, showing only mild repigmentation.

Keratoacanthoma in vitiligo lesion after UVB narrowband phototherapy.

The treatment of vitiligo is still a challenge. Among various therapeutic modalities, phototherapy with UVB narrowband (UVB-NB) is presently considered a treatment of choice for this skin disease. The exact skin cancer risk deriving from UVB-NB is a serious concern to be determined. We report a case of keratoacanthoma developed in the vitiligo area during a prolonged course of UVB-NB therapy.

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. PUVAand 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.

Photofibrosis: a further histopathological change induced by PUVA therapy via the mast cell in guttate psoriasis. Preliminary report.

Twenty-five psoriatic patients were studied histologically before and after PUVA therapy in order to delineate the relationship between dermal mast cells, psoriasis healing process and collagen changes. A number of mast cells were found in the psoriatic changes. A number of mast cells were found in the psoriatic lesion both before PUVA and also after PUVA therapy in 22 of the 25 patients. Fibrosis of the papillary dermis and upper reticular dermis was found in 3 cases. Increased collagen deposition and increased numbers of fibroblasts were accompanied by verticalization of ectatic and elongated blood vessels, with an overall pattern of relatively recent scarring. Mast cells were no longer detectable in the fibrosis area. We cannot exclude the possibility that PUVA therapy exerts a further stimulus on mast cell histamine and heparin degranulation in this type of psoriasis, thus leading to dermal fibrosis and blood vessel neogenesis.

PUVA-treated psoriatic skin as a model for cutaneous wrinkling assessed by skin replicas.

Psoriatic patients may offer a useful model for PUVA-induced skin wrinkling. This study deals with the changes induced by PUVA therapy on the cutaneous microrelief of psoriatic patients assessed by surface replicas. A non-exposed body area (buttocks) was considered. The microrelief was evaluated by means of replicas analysed by an automatic image analyser. Three groups of patients were considered: 1) 10 psoriatic patients who had been undergoing PUVA treatment for the first time and who had received a total PUVA dose of 200 +/- 20 J/cm2; 2) 16 psoriatic patients in long-term PUVA treatment (> 1000 J/cm2); 3) 13 psoriatic controls whose buttocks had never been affected by psoriasis nor exposed to sunlight or PUVA. The results showed that the number and the entity of the cutaneous crests and furrows had been increased by PUVA therapy. In particular the skin pattern analysis showed significant statistical differences between the second and the third group, while no changes were evident between the first and third group (ANOVA and Tukey test for multiple comparisons). In conclusion, our findings indicate that long-term PUVA therapy causes marked changes in the cutaneous microrelief, that this phenomenon can be measured non-invasively and that the changes observed are dependent on the PUVA-dose energies received.

Bullous lesions in acrodermatitis enteropathica. Histopathologic findings regarding two patients.

Acrodermatitis enteropathica (AE) is an autosomic recessive disorder affecting early infancy. Two cases of infantile AE with low plasma zinc levels are reported in which unusually prominent bullous and vesicobullous lesions were seen on the hands and feet, in addition to the more typical erythematous and scaly patches. Both psoriasiform and bullous lesions responded dramatically to oral zinc-sulfate supplementation. The histopathologic features of the bullous lesions of AE have not previously been fully examined. Histologically, the bullous lesions were characterized by intraepidermal vacuolar changes with massive ballooning, leading to intraepidermal vesiculation and blistering, with prominent epidermal necrosis and with no acantholysis. The bullous lesions did not arise on erythematous patchy lesions, but developed ex novo on unaffected skin. The histopathologic differential diagnosis with other bullous conditions is discussed.

Evidence for CD8+ cell increase in long-term PUVA-treated psoriatic patients after PUVA discontinuation.

Long-term PUVA-treated psoriatic patients given maintenance therapy (UVA doses greater than 1,000 J/cm2) have been demonstrated to undergo lymphopenia and a decrease in the total number of circulating CD3+ and CD4+ T cells. The aim of this study was to assess whether the impairment of T cells is detectable also in psoriatic patients after long-lasting PUVA discontinuation. A group of 34 psoriatic patients (25 males, 9 females; mean age 52.7 +/- 12.82 years), who had previously been treated by PUVA therapy (average cumulative dose 1,898.48 +/- 1,207.12 J/cm2), was studied 1 year or more after discontinuation of PUVA therapy. The patients studied failed to show any impairment in CD3+ and CD4+ cells. Nevertheless, a significant increase (p less than 0.05) in circulating CD8+ cells (both in the percentage and the total number) was detectable in PUVA patients as compared to appropriate controls. The significance and implications of this finding are not known and need further investigations.

Lymphopenia and decrease in the total number of circulating CD3+ and CD4+ T cells during 'long-term' PUVA treatment for psoriasis.

The relationship between high-dose PUVA treatment in psoriatic patients and peripheral T lymphocyte subsets (total number and percentage) has been studied. Of the two groups of patients considered, the first included 19 patients, all affected by chronic, progressively worsening psoriasis; they had never been previously treated by photochemotherapy. The second group included 13 psoriatic patients, who had received an average cumulative dose of 2,007.69 +/- 1,191.05 J/cm2. The 'long-term' PUVA-treated group was assessed while undergoing maintenance therapy. No significant differences were found between untreated patients and healthy controls for any of the parameters considered. A significant reduction (p less than 0.05) in the total number of lymphocytes in long-term PUVA-treated patients both versus untreated patients and controls was found. Furthermore, long-term PUVA-treated patients showed a significant reduction (p less than 0.05) in the percentage of lymphocytes as compared with controls. The reduction in the total number of CD3+ and CD4+ T cells was, moreover, significant (p less than 0.05) as compared with untreated patients. The impairment of circulating CD3+ and CD4+ T cells (total number) was only on the borderline of statistical significance vis-à-vis controls. These findings suggest the usefulness of a careful assessment of circulating T lymphocyte subsets in patients who undergo long-term PUVA therapy.

Effects of medium-term PUVA therapy on peripheral T-lymphocyte subsets in psoriatic patients.

Three to four months' PUVA treatment is a widely-adopted procedure to induce psoriasis remission and for the purpose of this study is called "medium-term". The 32 psoriatic patients considered revealed a statistically significant baseline decrease in OKT3+ (p less than 0.001), OKT4+ (p less than 0.001) and OKT8+ (p less than 0.001) as compared with 40 healthy controls, while OKT4/OKT8 was normal. Variance analysis within the psoriatic group failed to reveal further significant variation in the immunological parameters during the 3 months under study. Nevertheless, there was a marked trend towards a reduction in OKT4+ cells and OKT4/OKT8 as compared with baseline values after 3 months. These results suggest that "medium-term" PUVA therapy does not statistically restore the pre-existing baseline changes in T-lymphocyte subsets of the psoriatic patients. The non-statistically significant effects as regards OKT4+ may be due to the small number of patients who reached 3 months' treatment (9 patients) but could be regarded as the first step towards the significant changes described here in long-term PUVA-treated psoriatic patients.