[Narrow-band UVB therapy in psoriasis vulgaris: good practice guideline and recommendations of the French Society of Photodermatology]. / La photothérapie UVB à spectre étroit dans le psoriasis vulgaire : utilisation pratique et préconisations de la Société Française de Photodermatologie.

BACKGROUND: Phototherapy, PUVA therapy and narrow-band UVB are recognised forms of first-line therapy for extensive and severe plaque psoriasis. Based on a systematic review of the medical literature, we propose a good practice guideline for the use of narrow-band UVB phototherapy in this indication. METHODS: We carried out a review of the literature published over the 20 years (1998 to 2009) in the online PubMed database. Our conclusions are based on the results of control studies or where these are absent, on a synthesis of the recommendations common practice approved by the experts of the French Society of Photodermatology. The levels of scientific proof given are based on the criteria defined by Sackett. RESULTS RECOMMENDATIONS: (1) Practical aspects. Irradiation cabins equipped with Philips TL01 tubes, either for monotherapy (42 tubes) or for combined therapy (21 UVB tubes and 21 UVA tubes), were to be certified (CE marking, ISO-DIN certification) and equipped with an accurate dosimetry system. Several valid and usable protocols exist. The indication was based on the severity and extent of the episode of psoriasis, the psychological consequences of the dermatosis, comparison of the benefit/risk ratios of the various available treatments, the ability of the patient to attend sessions (a vital factor in therapeutic compliance), the cumulative doses of UV from previous courses of treatment, and absence of contraindications, including the use of photosensitising medication. Informed consent was to be obtained from patients, who were given a validated information sheet (available at www.sfdermato.org). The study results and the value of maintenance therapy were not confirmed. (2) Adverse effects. The immediate adverse effects were generally of little consequence, with later effects alone posing problems. Because of the risk of induction of cataract, ocular protection must be used during sessions. In the absence of symptoms or known ocular disorder, prior ophthalmologic control is not considered necessary. The risk of skin cancer remains poorly defined, and this risk has not been clearly shown to be lower than with broad-spectrum UVB therapy or PUVA. The studies give no indication of the number of sessions after which therapy must be completely discontinued. In the absence of clear evaluation of oncogenic risk, it seems reasonable to set the maximum number of sessions of UVB TL01 phototherapy at 250 as with PUVA, and to include in this limit the total of all PUVA and TL01 phototherapy sessions for patients receiving both types of phototherapy (level of proof: B). In the absence of lesions requiring treatment in these areas, the face and male genital organs should be protected during treatment sessions. There is no currently available data concerning carcinogenic risk induced by TL01 in patients also on cyclosporine, methotrexate or biotherapies. In order to reduce risk and maintain patients' capacity to undergo further phototherapy sessions, we suggest (level of proof: A) the following measures: strict patient selection, use of combined synergistic therapies, annual examination of the skin and appendages of subjects receiving more than 150 phototherapy sessions, and the creation of nationally accessible patient phototherapy files. (3) Combined treatments. The purpose of such treatment is twofold: to reduce the risk of adverse effects while increasing the efficacy of TL01 phototherapy. Lesions should be sloughed before the start of phototherapy. Synergistic effects have been demonstrated for dermal corticosteroids and tazarotene, but such effects are less noticeable with topical vitamin D3 derivatives. If there are no contraindications to its prescription, we feel that acitretine has demonstrated efficacy in enhancing the effect of TL01 phototherapy. (4) Efficacy. Narrow-spectrum UVB phototherapy is considered highly effective in extensive psoriasis. At a rate of three sessions per week, it results in complete (or almost complete) eradication of lesions in 60 to 90 % of patients within 20 to 40 sessions (level of proof: A). However, the efficacy of this therapy varies according to plaque size and noticeably better results are obtained in guttate and nummular psoriasis than in psoriasis involving large plaques. CONCLUSION: Narrow-spectrum UVB phototherapy offers a good alternative to PUVA therapy since concomitant psoralen is not required, but there are few immediate adverse effects, there is less risk of drug-induced photosensitisation, and there is no need for skin or ocular photoprotection after sessions. We recommend this approach as the first-line phototherapy (level of proof: A) in children and adolescents, and in adults with extensive moderate psoriasis involving small superficial plaques. It may also be used in pregnant or breastfeeding women and in patients with renal or hepatic insufficiency. In addition, it is preferable for HIV-positive subjects (level of proof: C). However, PUVA therapy is preferable as first-line treatment in extensive severe psoriasis involving large thick plaques (level of proof: A) and in adults of phototypes IV to VI (level of proof: B); it should also be contemplated for psoriasis refractory to UVB TL01 (level of proof: B).

[Polymorphic light eruption: prophylaxis using a topical combination of antioxidants and UVA protection formulations]. / Lucite estivale bénigne: prévention par un topique associant des filtres anti-UVA et des antioxydants.

BACKGROUND: In a recent randomized, double-blind, placebo-controlled clinical study, the efficacy of a combination consisting of 0.25% alpha-glucosyl-rutin, 1% vitamin E and a broad-spectrum, highly UVA-protective sunscreen (sun protector factor 15 - persistent pigmentation darkening 6) regarding prevention of polymorphous light eruption was well demonstrated. We evaluated this combination under real solar exposure conditions. PATIENTS AND METHODS: Patients with three previous typical polymorphous light eruptions (including one in the last year) were included in an open prospective multicenter study. The preparation was applied every two hours after the first summer exposure. No topical or systemic treatments presumed to be effective against polymorphous light eruption were given concomitantly. Evaluation was performed after the summer by a dermatologist. RESULTS: Two of the 54 patients dropped out of the study, one for an adverse effect (contact dermatitis). At the end of the study following application of the test preparation, no eruption was seen for 35 patients (67%), with minor eruption for 10 patients (19%) and an marked eruption for 7 patients (13%). Pruritus (present in all patients the year before) was not seen in 36 patients (69%), was considered bearable for 36 patients and unbearable for only 3 patients compared to 27 before inclusion. For the dermatologists, efficacy was excellent for 35 patients and good for 7 patients, giving global efficacy of around 80%, with inadequate results in 10% of cases (5 patients). Concerning protection against erythema, the test product reduced sunburn by 60% compared with the previous year. DISCUSSION: Because of the high clinical efficacy of the product noted after UVA challenge tests and verified by this clinical study under actual conditions of exposure, it may be proposed as a new prophylactic treatment for polymorphous light eruption.

Efficacy of photochemotherapy on severe pruritus in polycythemia vera.

Pruritus may cause severe chronic discomfort to PV patients. Most of the usual treatments are not at all or only weakly efficient. Photochemotherapy using psoralen and ultraviolet A light may largely improve the clinical symptom of intractable itching, as observed in ten of the 11 cases presented, but maintenance therapy is generally necessary. The treatment may then improve the patient's quality of life.

[Contact photoallergic eczema caused by ketoprofen]. / Eczéma photo-allergique de contact au kétoprofène.

INTRODUCTION: Since 1983, several cases of allergy and photoallergic contact dermatitis to ketoprofen gel have been reported in Italy and Spain. In France, this drug has been available for topic applications since 1989 and no cases of photoallergy have been reported. CASE REPORT: We observed two cases of photoallergic contact dermatitis to ketoprofen (Profenid gel, Ketum gel). Imputability was suggested by clinical history and proven by patch-tests showing evidence of crossed photoallergy with fenofibrate in both cases. Photoallergic dermatitis to oxybenzone was associated in one case. COMMENTS: Ketoprofen is the predominant nonsteroid anti-inflammatory drug responsible for allergic and/or photoallergic contact dermatitis resulting from topic applications. Its prevalence is probably underestimated in France in light of the number of cases reported in certain Mediterranean countries. Cross reactive photoallergy to ketoprofen and fenofibrate can be explained by the common benzoly-ketone structure of these compounds. In case of skin reaction, the other drug should not be prescribed and benzophenone-containing cosmetics discouraged.

Photoallergy to hexamidine.

This report details the case of an atopic patient showing a photosensitivity caused by a hexamidine solution. Patch tests were negative but photopatch tests to hexamidine in water solution were positive, after irradiation by ultraviolet A (UVA); all control tests were negative. It is well-known that hexamidine can induce contact allergy but this case was the first reported in which UVA was implicated. This photoallergy can be explained by the structure of the hexamidine molecule, but the question is: why has there never been such a case reported before?

[Fenofibrate photoallergy]. / Photo-allergie au fénofibrate.

Photosensitization to lipid-lowering fibric acid derivatives are rare. We report a case of photoallergy induced by fenofibrate, proved by a positive UVA photo-patch-test. Evolution towards persistent photosensitization is probable, since photobiological abnormalities persisted during four months after fenofibrate was discontinued. The fact that patch-tests to various benzophenones were negative is not in favour of the benzophenone group being responsible for the photosensitization reaction.