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PubMed2005

A clinician's paradigm in the treatment of atopic dermatitis.

Successful management of atopic dermatitis requires a multipronged approach that includes skin barrier function care, use of topical or systemic agents, and identification and elimination of precipitating or exacerbating factors. Because the origin of atopic dermatitis is multifactorial and trigger factors differ among patients, treatment plans must be specific to the individual patient. This article offers an example of a permutational, or flexible, treatment paradigm. The approach utilizes 4 topical regimens--high-potency topical corticosteroids, lowest effective potency topical corticosteroids, topical calcineurin inhibitors (TCIs), or topical corticosteroid/TCI combinations--as initial therapy in a variety of induction protocols, as determined by the severity of a patient's condition and history. The paradigm permits treatment to progress from a chosen induction therapy to maintenance therapy. During the patient's induction therapy, as soon as an acceptable level of clearance is achieved, therapy should be adjusted to a maintenance regimen, such as monotherapy with either a TCI or a lowest effective potency topical corticosteroid (the latter used intermittently) or an alternation of the two agents. If there is no clearance or positive response with the initial induction protocol, the clinician should move to one of the alternative regimens.

Administration, Topical↗
PubMed2004

Narrowband UVB and cream psoralen-UVA combination therapy for plaque-type psoriasis.

BACKGROUND: Psoralen-UVA (PUVA) and narrowband UVB (311-nm) therapy are considered to be first-line phototherapies for patients with moderate to severe psoriasis. To reduce side effects as a result of systemic resorption of psoralens, topical PUVA therapies have been developed and proven to be effective in the treatment of psoriasis. OBJECTIVE: We sought to evaluate the combination therapy of narrowband UVB plus cream PUVA on selected psoriatic plaques compared with narrowband UVB or cream PUVA alone. METHODS: A total of 30 patients (Psoriasis Area and Severity Index score of 8-15) were included in the randomized study. The combination therapy consisting of narrowband UVB whole-body irradiation followed by cream PUVA therapy for selected psoriatic plaques was evaluated in 10 patients with chronic plaque-stage psoriasis. For comparison, the therapeutic efficacy, number of treatments, and cumulative UV doses until remission (Psoriasis Area and Severity Index score < 4) of cream PUVA therapy or narrowband UVB alone was determined in 10 patients, respectively. RESULTS: Both monotherapies induced clearance of psoriatic lesions in all patients within 5 to 7 weeks. Mean number of treatments for cream PUVA was 24 +/- 5; for narrowband UVB was 21 +/- 3. The mean cumulative UVA dose was 45.0 +/- 16.3 J/cm(2) and the mean cumulative UVB dose was 17.1 +/- 4.1 J/cm(2). Combination therapy resulted in complete clearance of lesions in all patients after 3 to 4 weeks. Mean number of treatment was 14 +/- 2, mean cumulative UVA dose was 18.7 +/- 4.7 J/cm(2), and mean cumulative UVB dose was 8.2 +/- 3.3 J/cm(2). The number of treatments (P <.001, analysis of variance), UVA dose (P <.001, t test), and UVB dose (P <.001, t test) were significantly reduced compared with both monotherapies. CONCLUSIONS: Our results indicate that a combination therapy of narrowband UVB plus cream PUVA appears to have a significantly higher efficacy compared with either monotherapy. The cumulative UV doses were significantly lower in the combination therapy. We conclude that cream PUVA can be used in addition to narrowband UVB for areas that tend to clear less quickly than the rest of the body.

Administration, Topical↗
PubMed1981

Psoriasis: current advances in etiology and treatment.

Psoriasis is a disease of major importance, the cause of which is unknown and treatment often difficult. However, research worldwide has intensified, and we now have an increased understanding of the events that lead to the production of a psoriatic lesion. Newer treatments and the revival of old therapies have increased the success rate in the management of this difficult disease but have also opened up new concerns regarding the safety of these modalities. This is a review of the current research on the etiology and treatment of psoriasis.

Administration, Topical↗
PubMed1983

Recent advances in the treatment of psoriasis.

Because psoriasis is a disease of unknown etiology, all treatments are based on empirical experience and diverse scientific theories. Although there is no present cure for psoriasis, many forms of therapy are effective in control of the disorder. These range from topical medications such as tar, anthralin, corticosteroids; phototherapy and photochemotherapy; systemic medication, including cytotoxic agents; and vitamin A analogues or retinoids. This report focuses on modifications of existing therapies based on advances in basic science knowledge and technology, combination therapies, as well as new therapeutic agents and new approaches to the treatment of psoriasis.

Anthralin↗
PubMed1998

Papular dermatitis (subacute prurigo, "itchy red bump" disease): pilot study of phototherapy.

BACKGROUND: Some patients with a subacute or chronic pruritic erythematous papular eruption are refractory to treatment. We previously described a number of these patients with papular dermatitis or subacute prurigo. OBJECTIVE: The purpose of this study was to examine the effectiveness of different types of phototherapy for treatment of papular dermatitis. METHODS: We reviewed the medical records of 11 patients who were diagnosed with papular dermatitis and who underwent phototherapy within the last 5 years. RESULTS: Eleven patients had a total of 17 phototherapy courses: psoralen-UVA (PUVA; 9), UVA/UVB light (3), and UVB alone (5). Within the PUVA treatment group, three of nine patients experienced total clearing, and six of nine patients experienced partial improvement. Although patients in all groups relapsed with time, overall the PUVA-treated patients had the best response rate and the best chance of the condition remaining clear after treatment was stopped. CONCLUSION: PUVA may be an effective treatment for papular dermatitis. The frequency of relapse indicates that maintenance treatments may be necessary for long-term control of the disease.

Aged↗
PubMed1997

A left-right comparison of UVB phototherapy and topical photochemotherapy in bilateral chronic hand dermatitis after 6 weeks' treatment.

We have compared the efficacy of local UVB phototherapy with topical (bath) photochemotherapy in 13 patients with bilateral chronic hand dermatitis. In each patient, one hand was treated with UVB phototherapy and the other hand with topical (bath) photochemotherapy. Both treatments moderately improved the chronic hand dermatitis after 6 weeks' treatment. We observed no significant differences in improvement between the modalities, but side-effects occurred more often on the photochemotherapy-treated side. Considering the similar responses and relative incidence of side-effects, we would advise starting treatment with UVB phototherapy and only using topical photochemotherapy if this fails.

Chronic Disease↗
PubMed1986

Effect of cutaneous hypoxia upon erythema and pigment responses to UVA, UVB, and PUVA (8-MOP + UVA) in human skin.

The effect of oxygen deprivation upon UVA-, UVB-, and PUVA-induced pigment and erythema responses in normal human skin was examined. Before exposure, varying degrees of hypoxia in the skin of the forearm were achieved by inflating a sphygmomanometer cuff applied to the upper arm. After the transcutaneously measured pO2 had stabilized, sites on the inner forearm were exposed to UVA, UVB, or 8-MOP + UVA radiation, to determine dose thresholds for the induction of erythema and pigmentation at different cuff pressures. Inflation of the cuff to greater than systolic pressure completely inhibited immediate and delayed pigment responses (IPD, DT) to UVA doses greater than 10 times the normal pigmentation threshold dose. UVA-induced delayed erythema responses were partially inhibited by cuff inflation: 2.7 times the minimal erythema dose of UVA was necessary to cause an erythema response when exposure occurred during vascular occlusion. In contrast, erythema and pigment responses to UVB and PUVA were unaltered by cuff pressures exceeding systolic pressure during exposure. Inhibition of UVA-induced erythema and pigment responses by vascular occlusion were reversed by the transcutaneous diffusion of 100% O2. These findings indicate that the cutaneous responses to UVA and UVB occur by separate pathways differing with respect to O2 dependence. Our findings agree with those of other studies which indicate that PUVA-induced phototoxicity and melanogenesis are not O2-dependent.

Administration, Topical↗
PubMed1981

Impaired contact hypersensitivity in untreated psoriasis and the effects of photochemotherapy and dithranol/UV-B.

Cell mediated immune reactivity was studied in eighty-five psoriasis patients and twenty-five healthy controls by an improved (quantitative) method for measuring contact hypersensitivity to 2,4 dinitrochlorobenzene (DNCB). Patients were sensitized with 50 micrograms DNCB, the lowest dose found to sensitize all healthy subjects. Responses to epicutaneous challenge with a series of concentrations of DNCB were measured as volumes calculated from diameter and thickness and the various groups were compared by the differences in the log dose-response curves. Patients with untreated psoriasis were less responsive than healthy controls; responses were less still in patients treated with dithranol/UV-B/tar and they were least of all in patients treated with photochemotherapy with 8-methoxypsoralen and UV-A (PUVA), particularly in those who pigmented least. Sensitization and challenge at different stages of treatment showed that both induction and elicitation of sensitization were impaired by PUVA. The possible relationship of these changes to DNCB metabolism, Langerhans cell damage and a decrease in circulating T cells is discussed. Although the clinical significance of the findings is unknown, treatment with dithranol/UV-B/tar has proved safe over many years of use.

Adult↗
PubMed1993

A comparison of narrow band phototherapy (TL-01) and photochemotherapy (PUVA) in the management of polymorphic light eruption.

Twenty-five patients suffering from severe polymorphic light eruption (PLE) were randomized to either photochemotherapy (PUVA) or narrow-band phototherapy (TL-01 UVB) treatment in early spring; patients receiving UVB were given placebo tablets to achieve a matching therapy procedure. During the 4 months following treatment, patient exposure to solar UVB was monitored with polysulphone badges. PLE occurrence, severity, and restriction of outdoor activity were recorded, using weekly diary-sheets. Analysis of covariance on this data, using the logarithm of UVB exposure as the explanatory variable, showed no significant differences between the treatments. TL-01 UVB is an effective alternative to PUVA in the management of PLE.

Adult↗