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Vitiligo is refractory to most therapeutic modalities. To assess the efficacy of a variety of PUVA therapies, we enrolled 596 subjects in a prospective study, and 230 were followed for up to 55 months. Various psoralen derivatives and dosage schedules were used. Each subject was examined at yearly intervals for therapeutic response and evidence of chronic PUVA toxicity. At 4 years after therapeutic inception, 29 (13%) developed lesions in remaining vitiliginous macules. Clinically, hyperkeratotic macules and hyperkeratotic, lichenoid, and telangiectatic papules were discerned. Histologic examination of these lesions revealed them to be actinic and lichenoid keratoses, verruca vulgaris, and hyperkeratosis with either hyperplasia or atrophy. No tumors were present. In perilesional skin, dermal collagen and elastic tissue degeneration, much greater in degree than reported in psoriatic skin, was observed. In this group of PUVA-treated patients, no increased risk of carcinoma was apparent during the follow-up period.
Despite differences in study populations, methodologies, and levels of psoralen plus UV irradiation at 320-400 nm (PUVA), results from 4 prospective studies of patients treated with PUVA support the hypothesis that the risk of squamous cell carcinoma is increased with prolonged exposure. Tumors that develop after PUVA exposure behaved like skin tumors associated with sun exposure. In view of the latency for cancer in humans, continued prospective follow-up is required if we are to determine the ultimate carcinogenic risk of this type of therapy.
OBJECTIVES: To assess the effectiveness of low level laser therapy in the treatment of venous leg ulcers. SEARCH STRATEGY: Searches of 19 databases, hand searching of journals and conference proceedings from 1948 onwards, and examination of bibliographies. SELECTION CRITERIA: Randomised controlled trials comparing low level laser therapy with: sham laser; no laser; non-coherent light. There was no restriction on date or language. The main outcome measure used was complete healing of the ulcers. DATA COLLECTION AND ANALYSIS: Data extraction was done by one reviewer and checked by a second. Meta analysis was used to combine the results of trials where the interventions and outcome measures were sufficiently similar. MAIN RESULTS: There were 4 eligible trials. Two RCTs compared laser therapy with sham, 1 with ultraviolet therapy and 1 with non-coherent, unpolarised red light. Neither of the two RCTs comparing laser with sham found a significant difference in healing rates; there was no significant of laser evident when the trials were pooled. A three-arm study compared: - laser therapy alone - laser therapy plus infrared light - non-coherent, unpolarised red light. Significantly more ulcers completely healed in the group receiving a combination of laser and infrared light compared with non-coherent, unpolarised red light. A fourth trial compared laser and ultraviolet light and found no difference. REVIEWER'S CONCLUSIONS: We have found no evidence of any benefit associated with low level laser therapy on venous leg ulcer healing. One small study suggests that a combination of laser and infrared light may promote the healing of venous ulcers, however more research is needed.
BACKGROUND: Ultraviolet (UV) radiation is known to be an important etiologic agent in the development of skin cancer. Keratoacanthoma is an unusual, well-described cutaneous neoplasm that resembles squamous cell carcinoma but spontaneously resolves. Rarely, multiple keratoacanthomas may develop. OBJECTIVE: We present a case of multiple keratoacanthomas in a patient with psoriasis who had received UVB phototherapy. These lesions were hyperkeratotic papules, many of which spontaneously resolved and demonstrated the histologic characteristics of keratoacanthoma. CONCLUSION: We believe that UV radiation is the most likely etiologic factor in this patient's development of multiple keratoacanthomas. We wish to bring to the attention of clinicians this unusual adverse effect of UV treatment.
CONTEXT: Each year tens of thousands of patients in the United States are treated with UV-B radiation or psoralen plus UV-A radiation (PUVA) for a variety of skin disorders. Although PUVA is generally considered more effective, it is also more toxic and more expensive. The degree of consensus among experts in prescribing these alternative treatments has not been quantified. OBJECTIVES: To quantify variation among specialty clinics in the type of ultraviolet therapy used to treat specific skin conditions and assess factors associated with the use of specific treatments. DESIGN: Survey conducted during two 2-week periods in the late fall of 1994 and early spring of 1995. SETTING: Thirty-nine specialty clinics in 17 US geographic areas in 14 states and Washington, DC. PARTICIPANTS: A total of 3401 patients treated with UV radiation one or more times. OUTCOME MEASURES: Type of UV therapy used and indications for treatment, age, sex, number of patients treated, and geographic location of each clinic. RESULTS: The proportion of patients at each center treated with PUVA ranged from 0% to 93% (mean, 41%). Clinic size and geographic location, demographic characteristics of the patients, and diagnosis did not explain these large intercenter differences. CONCLUSIONS: Among specialized clinics, there is little consistency in the use of alternative therapies, which differ substantially in safety and cost, but whose relative efficacy is not well quantified. There is a lack of consensus among experts about the circumstances in which the greater risks and costs of PUVA are outweighed by its possibly greater efficacy, especially in the treatment of psoriasis.
Psoriasis was already mentioned in the Corpus Hippocratium and only 1842 was it possible to separate this entity from lepromatous skin manifestations. Psoriasis is rather common and the prevalence in northern countries ranges between 1-2%. Psoriasis is an inherited disorder but the clinical manifestations depend on several triggers such as infections, drugs and stress. The clinical presentation is characterized by silvery scales on an erythematous ground. The management of psoriatic patients needs a broad experience. The objective degree of disease activity as well as the subjective aspects of the disease need to be taken in account. The therapeutic modalities used in the treatment of psoriasis can be compared with a symbolic ladder. At the beginning of the ladder emollients are to be mentioned. Ascending the ladder, different topical treatments can be used such as steroids or vitamin D and the more severe forms do need systemic treatments such as ultraviolet therapy, eventually combined with a photosensitizer, retinoids or methotrexate and even cyclosporine. In special cases treatment as an outpatient is not possible and then hospitalisation in a dermatologic unit is necessary.
Seventeen cases of pityriasis lichenoides diagnosed over a nine-year period in children under 15 years of age are reported. Patients with this benign disease develop papular skin lesions covered with thick, coherent scales which detach in a single piece (reminiscent of sealing wax). Pruritus is not marked. Lesions may be necrotic (Mucha Habermann's small pox-like form, n = 6) or mild (leukodermic form, n = 2). Half of the patients studied developed several episodes and total duration of the disease exceeded two years in one third of cases. Recovery occurred after one or two episodes in half the children. Scars developed in some patients with severely necrotic lesions. None of the patients developed lymphoma. All patients with lymphomatoid papulosis progressing to lymphoma reported in the literature were adults. Pathogenesis of pityriasis lichenoides remains unknown but may involve lymphocytic vasculitis. No truly effective therapy is available. However, oral macrolides can be used especially in patients with early manifestations suggesting an infectious disease. Emollients, heliotherapy and ultraviolet therapy may also be recommended.
Streptococcus pyogenes (group A streptococcus--GAS) is a common cause of necrotizing fasciitis (NF)--a severe infection of the subcutaneous soft tissue. The purpose of this study was to determine if the topical therapy ultraviolet light C (UVC) is effective in killing GAS in vitro and to evaluate the most effective treatment parameters for use with UVC therapy. Five replications of GAS at 10(8) organisms/mL were plated. The cultures were treated with a UVC light 1 inch from the surface. Irradiation times were as follows: 0, 2, 3, 4, 5, 15, 30, 45, 60, 90, 120, and 180 seconds. Bacterial cultures were incubated and colony counts performed. A second set of GAS cultures were exposed to UVC for 30, 90, and 120 seconds either once daily (qd) or twice daily (bid). Kill rates were 99.9% for GAS at 4 seconds to 180 seconds. Kill rates of 99.9% were also obtained at 30 seconds and 90 seconds when UVC treatment was given either qd or bid. This data indicates that UVC is bactericidal for GAS at times as short as 4 seconds. In addition, UVC treatment was not effective when administered through thin film dressings.
BACKGROUND: Patients with chronic renal insufficiency (CHRI) frequently suffer from generalized pruritus, which is difficult to palliate. One of the treatments with favourable effect on pruritus is UV radiation. METHODS AND RESULTS: Fifteen patients were exposed to UVB radiation in doses from 20 to 45 s or from 1 min and 20 s to 18 min (i.e. 0.09-0.18 J/cm2 to 1.9-4.32 J/cm2). Ten of the treated patients reported a marked regression of pruritus, three a slight relief and two of them did not notice any change in the intensity of itching. Another four patients were exposed to the UVA radiation from 0.5 J/cm2 to 10.0 J/cm2 With exception of one female patient non-of them revealed any improvement in the intensity of pruritus the irradiation. CONCLUSIONS: UVB is probably highly effective on inhibition of pruritus and thus can be used as an efficient method, which extends contemporary antipruriginous treatment of patients with CHRI. However, so far it is difficult to explain its favorable effect.
BACKGROUND: Narrowband ultraviolet B (NBUVB) has recently been reported to be effective therapy for vitiligo. However, reports on its efficacy in recalcitrant vitiligo are lacking. OBJECTIVE: Our objective was to assess the efficacy of NBUVB in patients with vitiligo who did not respond to either topical therapy or oral psoralen plus ultraviolet A (PUVA). METHOD: This was a retrospective analysis of patients with vitiligo who were treated with NBUVB from February 1998 to January 2001. They received NBUVB treatment 2 times per week, with an initial dose of 100 mJ/cm(2). The dose was increased by 10% to 20% per treatment for 20 treatments. The dose was then increased by 2% to 5% per treatment until 50% repigmentation was observed or persistent erythema developed. The treatment was continued until maximum repigmentation was achieved. The treatment was terminated if the patient showed less than 25% improvement after 40 to 50 exposures. RESULTS: There were 60 patients: 22 men and 38 women, aged 11 to 61 years. The mean duration of vitiligo was 8.2 +/- 7.1 years. There were 53 cases of generalized and 7 cases of localized vitiligo. The lesions covered from less than 5% to 50% of body surface. Twenty-five patients were skin type III, 33 patients were skin type IV, and 2 patients were skin type V. Every case had been previously treated with topical steroid with or without topical psoralen with solar light exposure. Thirty-six patients (60%) had been treated with oral PUVA before NBUVB therapy. After NBUVB treatment, 25 of 60 patients (42%) achieved more than 50% repigmentation on face, trunk, arms, and legs. However, hand and foot lesions showed less than 25% repigmentation in all cases. There was no significant difference between the responders and nonresponders in age, sex, duration of diseases, and skin type. The response rate of patients who had not been previously treated with PUVA was significantly higher than that of patients who had been previously treated with PUVA (67% vs 36%, P =.003). CONCLUSION: This retrospective, open study demonstrated that NBUVB therapy was effective in 42% of Asian patients with recalcitrant vitiligo without serious side effect. The only clinical parameter that could differentiate nonresponders from responders was previous exposure to PUVA.
Therapy with methoxsalen and type A (long-wavelength) ultraviolet radiation (PUVA) has recently become a common method of treating psoriasis and other dermatologic conditions. This treatment could induce cataractous changes in the human lens through a reaction between the psoralen in the lens and either UVA or ambient light. In a 28-month-long prospective study of 78 patients treated with PUVA, small lens opacities appeared in 3 patients, aged 67, 48 and 32 years. The two younger patients had not worn their protective glasses for 24 hours after each treatment, as recommended. Therefore, although it cannot be concluded that PUVA therapy caused these opacities, eye protection during treatment and for 24 hours thereafter should be emphasized to the patients.
Pediatric dermatology is a new topic and no epidemiologic data exist from Switzerland. Therefore we performed a survey of the pediatric population referred to the hospital of Aarau, Switzerland, between 1998 and 2001. All inpatients and outpatients less than 16 years old with a dermatologic diagnosis were included prospectively in our study. Demographic data (age, mean age, sex distribution), referral method, pattern and frequency of the different diagnoses in various age groups, diagnostic pattern, and therapy were analyzed. A total of 1105 children were included, with a slightly higher proportion of girls (53.8% versus 46.2%). The average age was 6.8 years and infants and school children represented 60% of the study population. Half of the patients (51%) were external referrals, almost one-third (29%) presented spontaneously, and the remaining 20% were sent from other hospital departments. With a frequency of 25.9%, atopic dermatitis was the most frequent diagnosis, followed by pigmented nevi (9.1%) and warts (5.0%). Local therapy was prescribed in 66% of patients and systemic therapy in 18.6%. Other treatments such as curettage, surgery, cryotherapy, ultraviolet therapy, and electrotherapy were rarely performed (2%). We found that atopic dermatitis was the most frequent skin disorder seen in all age groups. As this was a dermatologic subspecialty clinic, higher frequencies of chronic and uncommon dermatoses such as genetic and autoimmune diseases were seen, whereas frequent diagnoses such as diaper rash and miliaria were rarely seen and the frequencies of other common skin disorders such as scabies, pediculosis, impetigo contagiosa, warts, and molluscum contagiosum were expected to be higher compared with the figures in the literature. In our study these dermatoses are underreported, as most patients are treated by general practitioners and pediatricians. Our survey documents the most common skin diseases in childhood primarily seen by pediatricians. We emphasize that dermatologic education of medical students, primary care physicians, and pediatricians should focus on allergic skin diseases, skin infections, pigmentary disorders, and vascular lesions.