PUVA psoriasis

PUVA) monotherapy, tacalcitol plus PUVA and tazarotene plus PUVA in patients with chronic plaque-type psoriasis. Br J Dermatol 147 748-753... 

Sequential therapy involves rapid clearing of psoriasis with aggressive therapy (e.g., cyclosporine), followed by a transitional period in which a safer drug such as acitretin is started at maximal dosing. Subsequently, a maintenance period using acitretin in lower doses or in combination with UVB or PUVA can be continued. 

Psoriasis Neoral and Gengraf are indicated for the treatment of adult, nonimmunocompromised patients with severe (ie, extensive and/or disabling), recalcitrant, plaque psoriasis who have failed to respond to at least 1 systemic therapy (eg, PUVA, retinoids, methotrexate) or in patients for whom other systemic therapies are contraindicated or cannot be tolerated. While rebound rarely occurs, most patients will experience relapse with Neoral or Gengraf as with other therapies upon cessation of treatment. 

Hypersensitivity to polyoxyethylated castor oil (injection only see Warnings and Administration and Dosage), cyclosporine, or any component of the products Gengraf and Neoral in psoriasis or RA patients with abnormal renal function, uncontrolled hypertension, or malignancies Gengraf and A/eora/concomitantly with PUVA or DVB, methotrexate or other immunosuppressive agents, coal tar or radiation therapy in psoriasis patients. 

Acitretin is most useful for the treatment of severe psoriasis, particularly the pustular and erythrodermic variants. Psoriatic nail changes and arthritis also may respond. Combining the drug with ultraviolet light therapy (Re-UVB, in the case of ultraviolet B radiation, or Re-PUVA, with psoralen plus ultraviolet A radiation) permits the use of lower doses of both acitretin and ultraviolet radiation. Other conditions for which the drug may be especially useful include congenital and acquired hyperkeratotic disorders, such as the ichthyoses and palmoplantar keratodermas, and severe lichen planus. 

PUVA is most useful for the treatment of severe psoriasis. Early (patch and plaque) stage cutaneous T-cell lymphoma (CTCL) also responds to PUVA therapy. In addition, patients in advanced stages of CTCL have been treated with a modification of PUVA known as extracorporeal photopheresis. In this therapy, blood from a CTCL patient who has taken psoralen is exposed to UVA light and returned to the patient. Lymphocytes are altered or destroyed by the treatment, and theoretically, the return of these abnormal cells triggers an immune response directed against certain lymphocyte surface antigens. The effectiveness of this modality appears to be variable. 

Recognition of the photosensitizing effect of the naturally occurring furanocoumarin psoralin (desmethoxy (3-6)) led to trials of its utility for the treatment of skin diseases such as psoriasis. The partial effectiveness of this compound led to the preparation of synthetic analogues. The two commercially available drugs, methoxsalen (3-8) and trioxsalen (4-6), are used in a procedure that goes by the acronym PUVA (psoralen and UVA irradiation) for the treatment of psoriasis and other skin diseases. 

For treating psoriasis, UVB phototherapy and PUVA are effective treatments that permit rapid control of the disease, but their side effects are similar to those of radiotherapy and chemotherapy. While these treatments can suppress the pathogenic change and rapidly improve the skin lesions, the heat penetrates into the blood, consumes the blood and Yin, and generates heat-toxin. Once the therapy is finished, the heat quickly arises and the skin lesions appear again, even worse than before the treatment, and the skin becomes more sensitive in general. In herbal treatment, one needs to reduce the heat-toxin, cool the blood, promote blood circulation and nourish the Yin. 

Gasparro, F.R The role of PUVA in the treatment of psoriasis. Photobiology issues related to skin-cancer incidence. Am J Clin Dermatol. 1, 337, 2000. 

DNA (intercalation) (photosensitive yielding crosslinks) [dermatitic, mutagenic, phototoxic, PUVA therapy for leucoderma psoriasis]... 

In the presence of UVA the psoralen interacts with DNA, forms thymine dimers, and inhibits DNA synthesis. Psoralen plus UVA (PUVA) treatment is used chiefly in severe psoriasis (a disease characterised by increased epidermal proliferation), and cutaneous T cell lymphoma. 

Ultraviolet B light is effective in guttate psoriasis and potentiates the effects of topical agents such as calcipotriol and dithranol. A psoralen followed by ultraviolet light (PUVA) is used in severe cases (see Psoralens, p. 306). 

It is plain from this brief outline that treatment of psoriasis requires considerable judgement and choice will depend on the patient s sex, age and the severity of the condition. The combination of UVB and dithranol is probably the safest. When psoriasis is moderate-to-severe a strategy of rotation of treatments, e.g. UVB plus dithranol —> PUVA + acitretin —> UVB plus dithranol and so on may help to reduce the unwanted effects of any one therapy. 

Photochemotherapy, which consists of oral (and sometimes topical) administration of psoralens (the furo-coumarins 5-methoxypsoralen, 8-methoxypsoralen, and trioxysalen) plus long-wave ultraviolet radiation, known as PUVA, is a well-established effective treatment for psoriasis, which has also been used for vitiligo (1), mycosis fungoides, alopecia areata, dyshidrotic eczema, atopic dermatitis, and certain other skin diseases. Guidelines for treatment have been recommended (2,3). 

Psoriasis of the nails Pustular psoriasis PUVA keratoses (26)... 

Hannnksela A, Pnkkala E, Hannuksela M, Karvonen J. Cancer incidence among Finnish patients with psoriasis treated with trioxsalen bath PUVA. J Am Acad Dermatol 1996 35(5 Pt l) 685-9. 

Calzavara-Pinton P, Franceschini F, Rastrelli M, Manera C, Zane C, Cattaneo R, De Panfilis G. Antinuclear antibodies are not induced by PUVA treatment in patients with uncomplicated psoriasis. J Am Acad Dermatol 1994 ... 

Studniberg HM, Weller P. PUVA, UVB, psoriasis, and nonmelanoma skin cancer. J Am Acad Dermatol 1993 29(6) 1013-22. 

Stern RS Nichols KT, Vakeva LH. Malignant melanoma in patients treated for psoriasis with methoxsalen (psoralen) and ultraviolet A radiation (PUVA). The PUVA Follow-Up Study. N Engl J Med 1997 336(15) 1041-5. 

In 1990, etretinate (Tigason) was replaced by acitretin (Neo-Tigason), an aromatic retinoid, a carboxylic acid metabolite of etretinate (15). It is effective in pustular psoriasis and psoriatic palmoplantar keratoderma and in combination with PUVA or topical therapy (calci-potriol or glucocorticoids) in the treatment of other forms of psoriasis. It has also been used to treat disorders of keratinization (ichthyosis, palmoplantar keratoderma, Darier s disease) and severe cutaneous forms of lichen planus. It prevents new skin carcinomas in patients with xeroderma pigmentosum and those who are immunosuppressed. The main advantage of acitretin is its short half-life of 50 hours, compared with over 80 days for etretinate (16). 

PUVA is used most commonly in the treatment of psoriasis, vitiligo, and cutaneous T-cell lymphoma. However, up to 30 other skin diseases have been reported to be responsive to PUVA therapy. The most common of these include palmarplantar pustulosis, polymorphous light eruption, dishydrotic eczema, atopic dermatitis, allergic contact dermatitis, actinic reticuloid, solar urticaria, pityriasis lichenoides, and graft versus host disease. 

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