Actualización en mastocitosis. Parte 2: categorías, pronóstico y tratamiento / Update on Mastocytosis (Part 2): Categories, Prognosis, and Treatment

Las mastocitosis constituyen un grupo heterogéneo de enfermedades caracterizadas por la proliferación clonal de mastocitos en distintos órganos, siendo la localización cutánea la más frecuente. La Organización Mundial de la Salud (OMS) clasifica las mastocitosis cutáneas en mastocitomas, mastocitosis máculo-papulosas y mastocitosis cutánea difusa, mientras que las formas sistémicas incluyen las mastocitosis indolentes, las agresivas, las asociadas a otra hematopatía monoclonal y la leucemia mastocitaria; el sarcoma mastocitario y el mastocitoma extracutáneo son variantes muy poco frecuentes. Aunque la evolución de la enfermedad en los niños es impredecible, con frecuencia las lesiones desaparecen durante la infancia; en los adultos la enfermedad tiende a persistir. El tratamiento se dirige a controlar las manifestaciones clínicas debidas a la acción de los mediadores mastocitarios, mientras que las formas agresivas requerirán de tratamientos dirigidos a reducir la masa mastocitaria

Mastocytosis is a term used to describe a heterogeneous group of disorders characterized by clonal proliferation of mast cells in different organs. The organ most often affected is the skin. The World Health Organization classifies cutaneous mastocytosis into mastocytoma, maculopapular cutaneous mastocytosis, and diffuse mastocytosis. The systemic variants in this classification are as follows: indolent systemic mastocytosis (SM), aggressive SM, SM with an associated clonal hematological non-mast cell lineage disease, mast cell leukemia, mast cell sarcoma, and extracutaneous mastocytoma. The two latest systemic variants are rare. Although the course of disease is unpredictable in children, lesions generally resolve by early adulthood. In adults, however, the disease tends to persist. The goal of treatment should be to control clinical manifestations caused by the release of mast cell mediators and, in more aggressive forms of the disease, to reduce mast cell burd

Metotrexato en el tratamiento de la psoriasis / Methotrexate in the treatment of psoriasis

La psoriasis es una enfermedad inflamatoria, de base genética, mediada inmunológicamente, con manifestaciones cutáneas preeminentes y asociada a comorbilidades sistémicas (osteoarticular, cardiovascular, diabetes, obesidad, enfermedad inflamatoria intestinal, cardiopatía isquémica, síndrome metabólico, ictus, hepatopatía, enfermedad psiquiátrica), lo que hace que su limitación patológica se extienda más allá de la piel. Afecta aproximadamente al 2,4% de la población española y, dado que actualmente no se dispone de curación definitiva, se requiere terapia a lo largo de la vida del paciente ajustada al control clínico de esta. Los tratamientos sistémicos clásicos (metotrexato, acitetrina, ciclosporina, luz ultravioleta), junto con las denominadas terapias biológicas disponibles actualmente (etanercept, infliximab, adalimumab, ustekinumab), permiten al dermatólogo disponer de un arsenal terapéutico más amplio y disponer, por lo tanto, de mayores posibilidades de control de pacientes con psoriasis grave y/o extensa. El metotrexato, un fármaco clásico en la terapia antipsoriásica, sigue siendo de gran utilidad, tanto en monoterapia como asociado a otros fármacos sistémicos, en especial como rescate o combinación con los biológicos. El objetivo de este artículo es establecer el papel del metotrexato en el tratamiento de la psoriasis (AU)

Psoriasis is a genetic, immune-mediated inflammatory disease with preeminent cutaneous manifestations associated with systemic comorbidities (osteoarticular, cardiovascular, diabetes, obesity, intestinal inflammatory disease, ischemic heart disease, metabolic syndrome, stroke, liver disease, psychiatric disease). Consequently, this disease has repercussions that go far beyond the skin. Psoriasis affects approximately 2.4% of the Spanish population. Currently, there is no definitive cure and consequently patients require lifelong treatment, with period adjustments based on the results of monitoring. Classic systemic therapies (methotrexate, acitretin, cyclosporine, ultraviolet light), together with currently available biological therapies (etanercept, infliximab, adalimumab, ustekinumab) provide dermatologists with a broader therapeutic armamentarium and therefore with greater possibilities for controlling severe and/or extensive psoriasis. Methotrexate, a classic drug in anti-psoriatic therapy, continues to be highly useful both in monotherapy and in combination with other systemic drugs, especially as rescue therapy or combined with biological agents. The aim of this article is to establish the role of methotrexate in the treatment of psoriasis (AU)

Fototerapia, una alternativa para el manejo de la forma crónica de enfermedad del injerto contra huésped (EICH) / Phototherapy for the management of chronic graft-vs-host disease

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Phototherapy for mycosis fungoides.

BACKGROUND: Both phototherapy and photochemotherapy have been used in all stages of mycosis fungoides since they improve the symptoms and have a favourable adverse effect profile. MATERIALS AND METHODS: We performed an extensive search of published literature using keywords like "phototherapy", "photochemotherapy", "NBUVB", "PUVA", "UVA1", "mycosis fungoides", and "Sezary syndrome", and included systematic reviews, meta-analysis, national guidelines, randomized controlled trials (RCTs), prospective open label studies, and retrospective case series. These were then arranged according to their levels of evidence. RESULTS: Five hundred and forty three studies were evaluated, of which 107 fulfilled the criteria for inclusion in the guidelines. CONCLUSIONS AND RECOMMENDATIONS: Photochemotherapy in the form of psoralens with ultraviolet A (PUVA) is a safe, effective, and well tolerated first line therapy for the management of early stage mycosis fungoides (MF), that is, stage IA, IB, and IIA (Level of evidence 1+, Grade of recommendation B). The evidence for phototherapy in the form of narrow-band UVB (NB-UVB) is less robust (Level of evidence 2++, Grade of recommendation B) but may be considered at least as effective as PUVA in the treatment of early-stage MF as an initial therapy. In patients with patches and thin plaques, NB-UVB should be preferentially used. PUVA may be reserved for patients with thick plaques and those who relapse after initial NB-UVB therapy. For inducing remission, three treatment sessions per week of PUVA phototherapy or three sessions per week of NB-UVB phototherapy may be advised till the patient achieves complete remission. In cases of relapse, patients may be started again on PUVA monotherapy or PUVA may be combined with adjuvants like methotrexate and interferon (Level of evidence 2+, Grade of recommendation B). Patients with early-stage MF show good response to combination treatments like PUVA with methotrexate, bexarotene or interferon-α-2b. However, whether these combinations hold a significant advantage over monotherapy is inconclusive. For late stage MF, the above-mentioned combination therapy may be used as first-line treatment (Level of evidence 3, Grade of recommendation C). Currently, there is no consensus regarding maintenance therapy with phototherapy once remission is achieved. Maintenance therapy should not be employed for PUVA routinely and may be reserved for patients who experience an early relapse after an initial course of phototherapy (Level of evidence 2+, Grade of recommendation B). Bath-water PUVA may be tried as an alternative to oral PUVA in case the latter cannot be administered as the former may show similar efficacy (Level of evidence 2-, Grade of recommendation C). In pediatric MF and in hypopigmented MF, both NB-UVB and PUVA may be tried (Level of evidence 3, Grade of recommendation D).

Recent advances in PUVA photochemotherapy and PDT for the treatment of cancer.

Since ancient times, many cultures worldwide found out independently that the topical administration of some photoactive natural products (mainly extracted from plants) followed by exposure to sunlight, might be an effective treatment of some skin diseases, thus accidently giving birth to the so-called photochemotherapy. In the attempt to resemble nature by exploiting its teaching, during the last two centuries, scientists tried to rationalize this knowledge in order to develop more effective therapeutic strategies and to understand in depth the mechanisms of action involved, expanding the potential application of this therapy to pathologies other than skin diseases, such as some types of tumors. In this paper we aim at giving an overview on results achieved to date on state-of-the-art photochemotherapy related to the treatment of cancer. The script is organized in three sections. Subsequent to a general introduction describing the origin and basic principles of photochemotherapy, the first section deals with the issue concerning the choice of the proper light sources for each type of therapeutic application, stressing the technological advances in the field (e.g. fiber optics). The second and the third sections provide an overview of the two clinically-established phototherapies to date, that is, PUVA photochemotherapy and PDT, respectively. Both sections are further subdivided into sub-paragraphs emphasizing specific relate topics such as principles and applications, employed light sources, and available data concerning anticancer activity. The third section also provides examples of non-conventional metal-based photosensitizers for PDT.

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.

Evaluación del resultado de la terapia con puva en pacientes con estadios tempranos de micosis fungoides: seguimiento a 8 años / Eight years follow up of patients with early stage cutaneous T cell Lymphoma in treatment with psoralen plus UVA

Antecedentes: en la actualidad existen muy pocos datos en la literatura acerca de la evolución a largo plazo de los pacientes con micosis fungoides (MF) en tratamiento con PUVA. (fotoquimioterapia con radiación ultravioleta tipo A). Objetivos: Conocer las características epidemiológicas y clínicas de los pacientes con diagnóstico de MF en tratamiento con PUVA en el servicio de dermatología del CES-Sabaneta, y determinar qué impacto tiene la terapia de mantenimiento en la prevención de recaídas y en la sobrevida. Métodos: se realizó un estudio descriptivo y retrospectivo, con los pacientes con diagnóstico de MF desde abril de 1997 hasta junio de 2005.

Background: PUVA is considered first line therapy in early stages of mycosis fungoides. There are few reports in the literature about the long term follow up of these patients. Objective: to describe the epidemiology and clinical characteristics of patients with early stages of mycosis fungoides in PUVA therapy, in the Dermatologic Center CES-Sabaneta. We wanted to know the relationship between PUVA therapy and patient’s evolution, response to treatment, survival rates, relapse and adverse effects. Methods: a single center, retrospective, descriptive study was done. We included all patients with confirmed diagnosis of mycosis fungoides, who assisted PUVA therapy between April of 1997 and June of 2005.

Un caso con excelente respuesta a efalizumab. Experiencia en el Hospital Universitario de Salamanca / A case of excellent response of efalizumab. Experience in the University Hospital of Salamanca

Antes de iniciar el tratamiento con efalizumab, o con cualquier tratamiento biológico, es necesario utilizar técnicas de valoración objetiva que nos permitan evaluar la actividad y la evolución de la psoriasis, para así poder justificar la indicación de la terapia biológica, así como valorar el porcentaje de respuesta al tratamiento, la pérdida de respuesta o su posible ineficacia. A pesar de sus limitaciones, el índice de intensidad y gravedad de la psoriasis (PASI) es la mejor opción disponible. La definición de psoriasis moderada se ha propuesto a partir de un PASI basal = 7 mientras que para la psoriasis grave es, según los distintos autores, 10 o 121. En la práctica clínica habitual, en la definición de la gravedad de la psoriasis y en la indicación de establecer un tratamiento sistémico es preciso valorar también otros parámetros, ya que algunas formas de psoriasis tienen un curso más agresivo (psoriasis eritrodérmica, pustulosa) y existen localizaciones (cabeza, genitales, manos, etc.) que interfieren más intensamente en la calidad de vida de los pacientes, con aumento de la disfunción social, de la discapacidad física y del deterioro psicológico 2,3. Todos los pacientes tratados con terapia biológica en nuestro centro hospitalario cumplen los criterios establecidos por la European Medicines Evaluation Agency (EMEA): pacientes adultos con psoriasis en placas crónica moderada grave que no han respondido o tienen contraindicada o no toleran otra terapia sistémica incluyendo ciclosporina, metotrexato o fototerapia (AU)

Before initiating treatment with efalizumab, or with any other biological treatment, it is necessary to use objective assessment techniques that allow us to evaluate the activity on course of psoriasis, thus being able to justify the indication of biological therapy and to evaluate the percentage of response to treatment, loss of response or its possible inefficacy. In spite of its limitations, Psoriasis Area and Severity Index (PASI) is the best available option. The definition of moderate psoriasis has been proposed as beginning with a baseline PASI =7 while serious psoriasis has a score of, according to the different authors, 10 or 121 In the usual clinical practice, other parameters must also be evaluated in the definition of the seriousness of psoriasis and in the indication of establishing a systemic treatment since some forms of psoriasis have a more aggressive course (erythrodermicpsoriasis, pustulous psoriasis) and there are locations (head, genitals, hands, etc.) that interfere more intensely with the quality of life of the patients, with increase of social dysfunction, physical incapacity and psychological deterioration 2,3. All of the patients treated with biological therapy in our hospital site fulfill the criteria established by the European Medicines Evaluation Agency (EMEA): adult patients with psoriasis in chronic moderate-to-serious ones who have not responded or in its use is contraindicated or who do not tolerate another systemic therapy, including, cyclosporine, methotrexate or phototherapy (AU)

Análisis de coste-efectividad modelizado comparando metotrexato con fototerapia tipo PUVA para la psoriasis moderada-severa en el Área de Salud de Badajoz / Cost-effectiveness analysis comparing methotrexate with PUVA therapy for moderate-severe psoriasis in the sanitary area of Badajoz

Objetivo. Realizar un análisis de coste-efectividad modelizado, usando un árbol decisión, comparando metotrexato y fototerapia tipo PUVA para la psoriasis crónica en placas moderadas-severas en el Área de Salud (AS) de Badajoz, durante el periodo de un año, desde la perspectiva societaria. Material y métodos. Se consideraron las variables eficacia (PASI50 [descenso del 50 % del PASI basal]) y seguridad (reacciones adversas). Se valoró como eficaz la mejoría del PASI50. Se tomaron datos de la literatura médica dermatológica, fundamentalmente revisiones generales, revisiones sistemáticas y ensayos clínicos aleatorizados. Los regímenes de tratamiento se obtuvieron de las recomendaciones de grupos de trabajo y documentos de consenso, recogidos en publicaciones médicas. Como costes directos se consideraron los costes unitarios por consulta, los de las pruebas de monitorización, los de la medicación y las sesiones de fototerapia y los de las reacciones adversas. En los costes indirectos se valoraron los costes por desplazamiento, y los de productividad debidos a la pérdida de horas de trabajo de la jornada laboral. Resultados. El coste unitario por tratamiento con metotrexato sería de 952,79 euros (directos: 796,48; indirectos: 156,31). El coste unitario por tratamiento con PUVA sería 899,70 euros (directos: 383,36; indirectos: 516,34). El coste total del tratamiento durante un año con metotrexato sería 255.202,73 euros, y con PUVA 266.406,88 euros. Las ratios medias de coste-efectividad serían, para cada uno de los tratamientos: metotrexato 1.519,06 euros, y PUVA 1.085,18 euros por caso tratado eficazmente. La ratio incremental PUVA/metotrexato sería: 150,65 euros por cada caso añadido eficazmente tratado. Conclusiones. El tratamiento de la psoriasis durante un año en el AS de Badajoz con PUVA sería más caro, pero también más coste-efectivo que el tratamiento con metotrexato. Sin embargo, los costes indirectos (soportados por el paciente) del tratamiento con PUVA son más altos, lo que plantea un problema de equidad. Estos resultados deben considerarse a la luz de las limitaciones metodológicas de un estudio modelizado

Objective. To perform a cost-effectiveness analysis, by using a decision tree model, comparing methotrexate with PUVA therapy for moderate to severe chronic plaque psoriasis in the sanitary area of Badajoz (south-western Spain) over a one-year period. Material and methods. The following variables and data sources were included: efficacy (a 50 % reduction in the PASI) and safety (adverse reactions). Data were retrieved from the dermatologic medical literature, mainly general reviews, systematic reviews and randomized clinical trials. Therapy schedules followed current guidelines from work task teams and consensus documents. Direct costs included unitary costs of medical consults, costs of laboratory tests, pharmacy, phototherapy sessions and costs derived from adverse reactions. Indirect costs included travel expenses and costs of lost productive work time. Results. Unitary cost of methotrexate therapy would be 952.79 euros per treatment (direct cost: 796.48; indirect cost: 156.31). Unitary cost of PUVA therapy would be 899.70 euros per treatment (direct cost: 383.36; indirect cost: 516.34). Total cost of a one-year treatment with methotrexate would be 255,202.73 euros. Total cost of a one-year treatment with PUVA would be 266,406.88 euros. The average cost-effectiveness ratios per case effectively treated would be 1,519.06 euros for methotrexate therapy, and 1,085.18 euros for PUVA therapy. The incremental cost-effectiveness ratio of PUVA/methotrexate would be 150.65 euros for each additional case effectively treated. Conclusions. One-year treatment for moderate to severe psoriasis in the sanitary area of Badajoz would be more expensive but also more cost-effective with PUVA than with methotrexate. However, indirect costs (borne by patients), are higher for PUVA therapy, a fact that raises an issue of equity. The results should be interpreted taking into account the methodological limitations of a modelling study

Penfigoide ampolloso relacionado con tratamiento con PUVA: aportación de dos nuevos casos / Bullous pemphigoid related to PUVA therapy: Two further cases

El penfigoide ampolloso es una enfermedad de etiología autoinmune caracterizada por el desarrollo de ampollas subepidérmicas, que afecta generalmente a personas de edad avanzada. A pesar de que el penfigoide ampolloso tiene un potencial carácter fotosensible, se ha descrito de forma excepcional el desarrollo de dicho proceso en el curso de tratamiento con PUVA, sobre todo en pacientes con psoriasis. La asociación de penfigoide ampolloso y psoriasis plantea dificultad a la hora de instaurar un tratamiento y consideramos una buena alternativa la utilización de metotrexate, con o sin corticoides asociados, en el manejo de dichos pacientes. Aportamos dos nuevos casos de penfigoide ampolloso relacionado con tratamiento con PUVA en pacientes con psoriasis

Bullous pemphigoid is an autoimmune disease that generally affects elderly people and is characterised by the development of subepidermal blistering. Although bullous pemphigoid is potentially photosensitive, its occurrence during the treatment course with PUVA, especially in patients with psoriasis, has exceptionally been described. The association of bullous pemphigoid and psoriasis gives rise to difficulties when initiating treatment and we consider that the use of methotrexate, with or without associated corticoids, is a good alternative in the management of such patients. We report two further cases of bullous pemphigoid related to PUVA therapy in patients with psoriasis

Pápulas queratósicas acrales / Acral keratotic papules

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Histiocitoma eruptivo generalizado / Generalized eruptive histiocytoma

Presentamos el caso de un varón de 64 años que desarrolló, a lo largo de un periodo de 4 meses, múltiples pápulas asintomáticas distribuidas simétricamente por el tronco y las regiones proximales de las extremidades, respetando cuero cabelludo, palmas, plantas y mucosas. Las lesiones eran discretas, eritematoparduscas, redondeadas, desde ligeramente elevadas a hemisféricas, de 1 a 3 mm de diámetro, y firmes al tacto. Los estudios clínicos, histopatológicos, inmunohistoquímicos y ultraestructurales fueron de histiocitoma eruptivo generalizado. Las pruebas de laboratorio y los estudios radiológicos no mostraron hallazgos anormales. Tras someterse a fotoquimioterapia, las lesiones remitieron, pero más adelante aparecieron nuevos brotes de pápulas. El histiocitoma eruptivo generalizado pertenece a un espectro de enfermedades que pueden solaparse e incluso progresar las unas a las otras. Puesto que la enfermedad podría progresar hacia una dolencia más grave, habría que considerar seriamente revisiones regulares con exámenes clínicos, histológicos e inmunohistoquímicos

We present the case of a 64-year-old male who developed multiple asymptomatic papules over a four-month period, distributed symmetrically on the trunk and proximal regions of the limbs, while the scalp, palms, soles and mucous membranes were spared. The lesions were discrete papules, brownish-erythematous, rounded, ranging from slightly raised to hemispherical, from 1 to 3 mm in diameter and firm to the touch. Clinical, histopathological, immunohistochemical and ultrastructural studies were consistent with generalized eruptive histiocytoma. Laboratory tests and radiological studies did not show any abnormal findings. After being subjected to photochemotherapy, the lesions regressed, but later on new outbreaks of papules appeared. Generalized eruptive histiocytoma belongs to a spectrum of diseases that may overlap; some may even develop into others. As the disease may progress into a more serious ailment, regular checkups with clinical, histological and immunohistochemical examinations should definitely be considered

Documento de consenso sobre fototerapia: terapias PUVA y UVB de banda estrecha / Consensus document on phototherapy: PUVA therapy and narrow-band UVB therapy

La elaboración de un documento de consenso en fototerapia resulta imprescindible en el objetivo de adaptar este procedimiento a las peculiaridades, necesidades y realidad de nuestro ámbito. Tomando como referencia la revisión de la literatura existente al respecto y la experiencia propia de sus miembros, el Grupo Español de Fotobiología (GEF) de la Academia Española de Dermatología y Venereología (AEDV) ha elaborado unas guías terapéuticas para las modalidades de fototerapia más empleadas: terapia con psoraleno y radiación ultravioleta de longitud de onda A (PUVA) y terapia con radiación ultravioleta de longitud de onda B de banda estrecha (UVB-BE). En ellas se abordan generalidades acerca del utillaje, calibración y reglamentación en las cabinas de fototerapia, se revisan el concepto y las indicaciones de estas formas de tratamiento y se proponen recomendaciones referidas a la selección de pacientes, los procedimientos terapéuticos, las asociaciones farmacológicas de interés y la prevención y manejo de los efectos adversos. El documento de consenso se concibe como un instrumento flexible y práctico destinado a su empleo en la clínica diaria con el objetivo de optimizar las posibilidades de la fototerapia reduciendo los riesgos para pacientes y terapeutas

It is essential to develop a consensus document on phototherapy in order to adapt this procedure to the specific characteristics, needs and reality of our milieu. Using a review of existing literature on the subject and the experience of its own members as a reference, the Spanish Photobiology Group (GEF) of the Spanish Academy of Dermatology and Venereology (AEDV) has developed some therapeutic guidelines for the most widely used modes of phototherapy: PUVA therapy and narrow-band UVB (NBUVB) therapy. These guidelines deal with generalities about the equipment, calibration and regulation in phototherapy booths, and the concept and indications for these forms of treatment are reviewed. Recommendations are also proposed regarding patient selection, therapeutic procedures, associated pharmacological agents of interest and the prevention and management of adverse effects. The consensus document is designed as a flexible and practical instrument intended for use in daily clinical practice, aimed at optimizing the possibilities of phototherapy while reducing risks for patients and therapists

[New aspects in uv and photochemotherapy]. / Neuere Aspekte in der UV- und Photochemotherapie.

Recent data show that from a pharmacological point of view topical (cream or bath) PUVA therapy is superior to systemic PUVA. Due to a significant reduction of side effects compared to systemic PUVA, bath PUVA has now started to replace oral PUVA therapy. Narrowband UVB has proved to be superior to broadband UVB in the treatment of psoriasis and is effective for a number of dermatoses such as vitilgo, atopic dermatitis and polymorphic light eruption. UVA1 phototherapy is highly effective in the treatment of moderate to severe atopic dermatitis and sclerosing diseases of the skin. Data dealing with UVA1 phototherapy for other indications are still preliminary. High-dose UVA1 is has been widely replaced by medium-dose UVA1, as a number of studies have shown similar therapeutic efficacy of both dose regimens.

Selective immmunotherapy through extracorporeal photochemotherapy: yesterday, today, and tomorrow.

ECP's extensive clinical record, as well as a considerable improvement in the understanding of the mechanism that underlies its efficacy, opens potential novel strategies for the treatment of cancer, GVHD, transplant rejection, and autoimmunity. The low side effect profile of this therapy has made it a more attractive treatment consideration than current conventional chemotherapeutic and immunosuppressive medications. As the mechanism of action of ECP is more fully elucidated and clinical studies are completed, the role of ECP in modern therapeutics of CTCL and other malignancies, as well as in the treatment of other T-cell mediated diseases, will be become clearer.

Granuloma anular / Granuloma annulare

El granuloma anular es un proceso cutáneo inflamatorio de causa desconocida que aparece con mayor frecuencia en la infancia. El diagnóstico se basa, fundamentalmente, en la anatomía patológica, que demuestra la existencia de granulomas necrobióticos en la dermis. Los tratamientos actuales son poco efectivos; sin embargo, suele aparecer una evolución hacia la curación espontánea en el 50 por ciento de los casos, por lo que, a veces, no efectuar tratamiento es una opción aceptable (AU)