Treatment of severe, chronic hand eczema: results from a UK-wide survey.

Treatment of severe hand eczema (HE) that is resistant to topical potent corticosteroid treatment is challenging. In 2013, we surveyed 194 UK dermatologists to obtain information about their usual treatment pathways to inform the choice of the comparator in a trial of alitretinoin in severe HE (ALPHA trial); the results indicated that the treatment approaches favoured by UK dermatologists differ. Psoralen combined with ultraviolet A (PUVA) and alitretinoin were identified as the most frequent first-line treatment options for hyperkeratotic HE, whereas oral corticosteroids were identified as the most frequent first-line treatment for vesicular HE, followed by PUVA and alitretinoin. In terms of potential adverse effects of long-term or repeated use, oral steroids and ciclosporin A were reported to cause most concern. There is uncertainty about which treatment gives the best short and long-term outcomes, because of a lack of definitive randomised controlled trials evaluating the effectiveness of different treatment pathways in severe HE.

Photochemotherapy for systemic sclerosis: effect on clinical and molecular markers.

BACKGROUND: The cutaneous changes seen in systemic sclerosis (SSc) can result in considerable patient morbidity. AIM: We previously reported on the beneficial effect of psoralen ultraviolet A (PUVA) phototherapy in 13 patients with morphoea. We now report the findings of a study in which patients with SSc were treated with PUVA. METHODS: Twelve patients with SSc were treated with PUVA phototherapy. The effect on cutaneous disease activity was assessed using the modified Rodnan score, and the effect on serological and immunohistochemical growth factors and adhesion molecules was also measured. RESULTS: The median Rodnan score at baseline was 24.5 [interquartile range (IQR) 18.5-26.0]. The median number of treatments with PUVA was 24 exposures (IQR 20-26) with a median cumulative exposure of 68.3 J/cm(2) (IQR 28.6-139.8). Of the 12 patients, 11 responded well to phototherapy with a mean change in Rodnan score of 6.58 (36.98%) (P < 0.01, Wilcoxon signed ranks test). After treatment with PUVA there was a significant increase in circulating tumour necrosis factor-alpha levels in 8/12 patients (P = 0.03). In 7/12 patients there was an increase in E-selectin and vascular cell adhesion molecule, although this was not significant. CONCLUSIONS: PUVA treatment is associated with a significant improvement in cutaneous symptoms in patients with SSc as measured by the Rodnan score (P < 0.01). Specific lymphocyte markers, adhesion molecules and cytokines are also affected by this treatment, helping to clarify further the mechanism of action of PUVA treatment and our understanding of the primary pathological process.

Photochemotherapy for localized morphoea: effect on clinical and molecular markers.

BACKGROUND: Effective treatment options for morphoea remain limited. As a result, there has been increasing interest in the role of phototherapy in the management of this condition. Aims. We report the findings of a study in which 13 patients with localized morphoea were treated with oral (n = 11) and topical (n = 2) psoralen ultraviolet (PUVA) phototherapy. METHODS: The clinical effect on disease activity was assessed using a skin score adapted from the modified Rodnan score. The effect on serological and immunohistochemical markers was also measured. RESULTS: In total, 11/13 patients showed an improvement in their skin score after phototherapy, with the mean reduction in score being 62.9% (P = 0.003, Wilcoxon signed rank test). After treatment with PUVA, there was a fall in circulating levels of vascular cell adhesion molecule in 10/13 patients (P = 0.059) and a significant increase in tumour necrosis factor-alpha in 9 of 13 patients (P = 0.036). In the five patients in whom CD3 and CD4 was measured, all showed a reduction in CD3 (P = 0.025), with a fall in CD4 (P = 0.046) seen in four of the five patients. CONCLUSIONS: PUVA is associated with clinical improvement in patients with morphoea, as shown by significant improvement in the skin score. However, in one patient who had been simultaneously started on ciclosporin, this improvement could not be attributed to the phototherapy alone. Although the sample size was small, we also found that certain lymphocyte markers, adhesion molecules and cytokines are affected by this treatment, helping to further clarify the mechanism of action of PUVA treatment.

Combining PUVA therapy with systemic immunosuppression to treat progressive diffuse morphoea.

Cyclosporin and mycophenolate mofetil (MMF) are immunosuppressant agents now used frequently in the field of organ transplantation. More recently cyclosporin has been used for the treatment of a number of dermatological conditions, including severe psoriasis and eczema. Extensive diffuse morphoea is very difficult to treat. PUVA, UVA and a number of immunomodulating drugs have been used to attempt improvement but are most beneficial only in early disease. Combination treatments are often used in psoriasis, for example, but are not reported in morphoea. We present the case of a patient treated initially with cyclosporin and PUVA and subsequently with MMF and PUVA, with considerable improvement in his condition.

PUVA therapy in lichen aureus.

Lichen aureus is one of the subtypes of a rare group of diseases, pigmented purpuric dermatoses. The natural course of the disease is slow evolution and slow resolution. Treatment is generally limited. We report a case of lichen aureus that responded dramatically to photochemotherapy (PUVA).

Clinical aspects of the use of gamma linolenic acid in systemic sclerosis.

Systemic sclerosis is a multi system disorder, for which there is no satisfactory treatment. Theoretically, dietary supplementation with essential fatty acids may lead to an increase in their derivatives, the vasoactive prostaglandins, which benefit the acute and chronic ischaemic lesions of this disease. We assessed the value of concentrated essential fatty acids in patients with systemic sclerosis, concentrating particularly on vascular symptoms and objective tests of vascular reactivity. Twenty-five patients with systemic sclerosis were randomised to receive concentrated essential fatty acids or placebo, for 6 months in a double-blind parallel group study. There was no significant difference between the active and placebo groups in terms of maximum blood flow after warming, minimum blood flow after cooling or the recovery time after cooling. There were no significant differences between the groups in the other parameters measured. Dietary essential fatty acids have no role in the treatment of vascular symptoms in established systemic sclerosis.

Topical psoralen photochemotherapy (PUVA) and superficial radiotherapy in the treatment of chronic hand eczema.

The therapeutic efficacy of conventional superficial radiotherapy and topical psoralen photochemotherapy (topical PUVA) administered over a 6 week period was compared in a double-blind study of 21 patients with chronic bilateral constitutional hand eczema. One hand was treated with conventional superficial radiotherapy and the other with topical 8-methoxy-psoralen and long-wave ultraviolet light (topical PUVA). Significantly better clinical improvement was seen in superficial radiotherapy treated hands over topical PUVA treated hands after 6 weeks of treatment, but this difference was not maintained at 9 or 18 weeks. There was no significant difference in symptom severity between the two treatments after 6 weeks, but superficial radiotherapy produced significantly more symptomatic improvement at 9 and 18 weeks. Superficial radiotherapy is a less time consuming procedure than topical PUVA and leads to more rapid improvement.