Efficacy of UVA1 phototherapy in 230 patients with various skin diseases.Rombold S., Lobisch K, Katzer K, Grazziotin TC, Ring J, Eberlein B. Department.

Efficacy of UVA1 phototherapy in 230 Efficacy of UVA1 phototherapy in 230 patients with various skin patients with various skin

diseases.Rombold S., diseases.Rombold S., LobischLobisch K K, , KatzerKatzer K K, Grazziotin TC, Ring J, Eberlein B. , Grazziotin TC, Ring J, Eberlein B.

Department of Dermatology and Allergy Department of Dermatology and Allergy Biederstein, Technical University of Biederstein, Technical University of

Munich, Munich, Germany. Munich, Munich, Germany. [email protected]@gmx.de

Photodermatol Photoimmunol Photomed. Photodermatol Photoimmunol Photomed. 2008 Feb;24(1):19-23.2008 Feb;24(1):19-23.

IntroductionIntroduction

-In the past patients were treated with -In the past patients were treated with broadband UVB (280-320nm), broadband UVA broadband UVB (280-320nm), broadband UVA (320-400nm), or combination of both.(320-400nm), or combination of both.

-Broadband UV phototherapy is more and more -Broadband UV phototherapy is more and more replaced by irradiation devices that allow replaced by irradiation devices that allow treatment with selected emission spectra:treatment with selected emission spectra:

-UVB phototherapy which uses long wave -UVB phototherapy which uses long wave UVB radiation above 300nmUVB radiation above 300nm

-UVA1 phototherapy which uses long wave -UVA1 phototherapy which uses long wave UVA radiation above 340nmUVA radiation above 340nm

UVA1 phototherapyUVA1 phototherapy -available since 1981-available since 1981 -dosimetry: high doses (up to 130J/cm2), medium -dosimetry: high doses (up to 130J/cm2), medium

doses (40-70J/cm2), low doses (10-30J/cm2) for a single treatment. doses (40-70J/cm2), low doses (10-30J/cm2) for a single treatment. -safe in exacerbated atopic eczema, localized -safe in exacerbated atopic eczema, localized

scleroderma and granuloma annulare.scleroderma and granuloma annulare. -Effects:-Effects: -may contribute to suppression and -may contribute to suppression and

prevention of eczema flares by inducing T-lymphocyte apoptosis prevention of eczema flares by inducing T-lymphocyte apoptosis and reducing Langerhans Cells and mastocytes in the dermis.and reducing Langerhans Cells and mastocytes in the dermis.

-may contribute to improvement of -may contribute to improvement of morphea by increasing collagenase expression.morphea by increasing collagenase expression.

-may contribute to reduction of -may contribute to reduction of pruritus by inhibiting histamine release from basophile and mast pruritus by inhibiting histamine release from basophile and mast cells.cells.

-Well tolerated: side effects are erythema, -Well tolerated: side effects are erythema, hypopigmentation, polymorphic light eruption, pruritus due to hypopigmentation, polymorphic light eruption, pruritus due to druness of the skin and chronically photoaging and skin cancerdruness of the skin and chronically photoaging and skin cancer

Study design and methodsStudy design and methods -data collection in the Department of Dermatology and Allergy from August 1999 to June -data collection in the Department of Dermatology and Allergy from August 1999 to June

2005 (6 years). 2005 (6 years). -230 patients analysed:-230 patients analysed:

-86 with atopic dermatitis (39males, 27 females; age 40.22 +/- 16.6 years)-86 with atopic dermatitis (39males, 27 females; age 40.22 +/- 16.6 years)-54 with scleroderma (14 males, 40 females; age 46.17 +/- 19.12 years)-54 with scleroderma (14 males, 40 females; age 46.17 +/- 19.12 years)-20 with granuloma annulare (3 males, 17 females; age 57.90 +/- 10.13 years)-20 with granuloma annulare (3 males, 17 females; age 57.90 +/- 10.13 years)-19 with urticaria pigmentosa (3 males, 16 females; age 41.37 +/- 12.1 years)-19 with urticaria pigmentosa (3 males, 16 females; age 41.37 +/- 12.1 years)-17 with prurigo nodularis (7 males, 10 females; age 59.65 years +/- 16.89 -17 with prurigo nodularis (7 males, 10 females; age 59.65 years +/- 16.89

years)years)-10 with lichen sclerosus et atrophicus (1male, 9 females; age 64.4 +/- 7.49 -10 with lichen sclerosus et atrophicus (1male, 9 females; age 64.4 +/- 7.49

years)years)-7 with T-cell lymphoma (4 males, 3 females; age 67 +/- 19 years)-7 with T-cell lymphoma (4 males, 3 females; age 67 +/- 19 years)-5 with keratosis lichenoides chronica (1 male, 4 females; age 50.80 +/- 15.25 -5 with keratosis lichenoides chronica (1 male, 4 females; age 50.80 +/- 15.25

years)years)-4 patients with chronic urticaria (1 male, 3 females; age 46.75 +/- 11.98 -4 patients with chronic urticaria (1 male, 3 females; age 46.75 +/- 11.98

years)years)-3 males with scleredema adultorum Buschke (51, 59 and 60 years old)-3 males with scleredema adultorum Buschke (51, 59 and 60 years old)-2 patients with GVHD (1male, 1 female; 58 and 5 years old)-2 patients with GVHD (1male, 1 female; 58 and 5 years old)-1 patient (male) with nephrogenic fibrosing nephropathy-1 patient (male) with nephrogenic fibrosing nephropathy-1 female with Werner’s sndrome and eosinophilic fasceitis.-1 female with Werner’s sndrome and eosinophilic fasceitis.

-Patients receiving less than 6 treatments without worsening of the -Patients receiving less than 6 treatments without worsening of the skin condition were excluded from the study.skin condition were excluded from the study.

-Patients receiving less than 6 treatments WITH worsening of the -Patients receiving less than 6 treatments WITH worsening of the skin condition were included in the study.skin condition were included in the study.

-Clinical evaluation: by physician: level of pruritus, efficacy -Clinical evaluation: by physician: level of pruritus, efficacy evaluated by following scale:evaluated by following scale:

-- -2=withdrawal after 6 irradiations (worsened skin -2=withdrawal after 6 irradiations (worsened skin condition only)condition only)

-1=aggravation-1=aggravation0=status quo0=status quo1=slight improvement1=slight improvement2=moderate improvement2=moderate improvement3=marked improvement3=marked improvement4=complete remission4=complete remission

--UVA1 light=dermalight ultraA1 (Dr Hoenle GmbH, Kaufering, --UVA1 light=dermalight ultraA1 (Dr Hoenle GmbH, Kaufering, Germany): spectrum 340-440nm, intensity 80mW/cm2 at 50cm Germany): spectrum 340-440nm, intensity 80mW/cm2 at 50cm distance.distance.

Results Results

DiscussionDiscussion

In earlier studies with UVA1 , patients were treated with higher In earlier studies with UVA1 , patients were treated with higher doses comparing with earlier studies. This is why the mean single doses comparing with earlier studies. This is why the mean single doses vary accordingly to groups which include patients treated doses vary accordingly to groups which include patients treated earlier.earlier.

Atopic eczemaAtopic eczema Medium-dose UVA1 therapy in patients with atopic eczema led to a Medium-dose UVA1 therapy in patients with atopic eczema led to a

moderate to marked improvement in most patients as already noted moderate to marked improvement in most patients as already noted in earlier studies. UVA1 has already been shown to be superiorly in earlier studies. UVA1 has already been shown to be superiorly effective than UVA/UVB or PUVA therapy.effective than UVA/UVB or PUVA therapy.

High-dose UVA1 therapy has been shown to significantly improve High-dose UVA1 therapy has been shown to significantly improve clinically patients with severe atopic eczema. High-doses and clinically patients with severe atopic eczema. High-doses and Medium-dose UVA1 therapy have been shown to have a Medium-dose UVA1 therapy have been shown to have a comparable effect. In contrast Low-dose UVA1 therapy does not comparable effect. In contrast Low-dose UVA1 therapy does not lead to significant reduction in severity of atopic eczema.lead to significant reduction in severity of atopic eczema.

Although High-dose and medium-dose UVA1 therapy are effective, Although High-dose and medium-dose UVA1 therapy are effective, relapses typically 4-12 weeks after the last treatment.relapses typically 4-12 weeks after the last treatment.

SclerodermaScleroderma Improved in the study.Improved in the study. High dose decreases skin thickness ans stiffness.High dose decreases skin thickness ans stiffness. In other studies, low-dose and medium dose UVA1 are effective.In other studies, low-dose and medium dose UVA1 are effective. It has also been shown that medium-dose UVA1 therapy in localized It has also been shown that medium-dose UVA1 therapy in localized

scleroderma is significantly more effective than narrow-band UVB scleroderma is significantly more effective than narrow-band UVB treatment.treatment.

Lichen sclerosus et atrophicus and keratosis lichenoides chronicaLichen sclerosus et atrophicus and keratosis lichenoides chronica Medium-dose UVA1 has been shown to be effective in most cases Medium-dose UVA1 has been shown to be effective in most cases

of these lesions.of these lesions. Even with low-dose UVA1, clinical score, skin thickness and Even with low-dose UVA1, clinical score, skin thickness and

increase in dermal density have been demonstrated in lichen increase in dermal density have been demonstrated in lichen sclerosus et atrophicus.sclerosus et atrophicus.

PUVA is also effective.PUVA is also effective. In keratosis lichenoides chronica, clearance of 98%, 88%, 82% and In keratosis lichenoides chronica, clearance of 98%, 88%, 82% and

41% has been shown in 4 patients treated with medium-dose UVA1 41% has been shown in 4 patients treated with medium-dose UVA1 therapy.therapy.

Granuloma annulare:Granuloma annulare: Only half of patients with medium- to high-dose UVA1 therapy Only half of patients with medium- to high-dose UVA1 therapy

improved.improved. At a high dosage, results are controversial with some advocating At a high dosage, results are controversial with some advocating

that high-dose UVA1 leads to complete clearance or considerable that high-dose UVA1 leads to complete clearance or considerable improvement in all patients wheras others have shown that improvement in all patients wheras others have shown that substantial improvement or healing occurs in 50% of patients.substantial improvement or healing occurs in 50% of patients.

Relapses occur typically 3 months after last treatment.Relapses occur typically 3 months after last treatment. PUVA has been shown in more studies to be effective.PUVA has been shown in more studies to be effective.

Urticaria pigmentosaUrticaria pigmentosa Only half improved which is underestimated when compared with a Only half improved which is underestimated when compared with a

study where medium-dose UVA1 cleared all of patients (itch relief, study where medium-dose UVA1 cleared all of patients (itch relief, decrease of histamine and serotonine release)decrease of histamine and serotonine release)

Others showed that there was no difference between medium- and Others showed that there was no difference between medium- and high-dose. Pruritus and quality of life improved condiderably, even high-dose. Pruritus and quality of life improved condiderably, even though the number of lesions was not reduced.though the number of lesions was not reduced.

UVA1 therapy is thus worth trying in patients with urticaria UVA1 therapy is thus worth trying in patients with urticaria pigmentosa, but also bath PUVA therapy is effective.pigmentosa, but also bath PUVA therapy is effective.

Prurigo NodularisPrurigo Nodularis Quite effectiveQuite effective No studies published on UVA1 therapy and No studies published on UVA1 therapy and

prurigo nodularis.prurigo nodularis. Improvement has been shown in patients treated Improvement has been shown in patients treated

with NBUVB combined with thalidomide.with NBUVB combined with thalidomide.

Chronic urticariaChronic urticaria No effectNo effect Little data in the literature in UV light treatment.Little data in the literature in UV light treatment. Only solar urticaria can be successfully treated Only solar urticaria can be successfully treated

with UV hardening.with UV hardening.

GVHDGVHD One study shows that UVA1 therapy with low-One study shows that UVA1 therapy with low-

dose regimen and a high number of irradiations dose regimen and a high number of irradiations shows a moderate improvement whereas a shows a moderate improvement whereas a medium-dose regimen with a less number of medium-dose regimen with a less number of irradiations shows no effect.irradiations shows no effect.

Nephrogenic fibrosing nephropathyNephrogenic fibrosing nephropathy One study shows that medium-dose UVA1 leads One study shows that medium-dose UVA1 leads

to slight improvement similar to another study.to slight improvement similar to another study.

ConclusionConclusion

Good effects of UVA1 therapy in atopic Good effects of UVA1 therapy in atopic eczema, scleroderma, lichen sclerosus et eczema, scleroderma, lichen sclerosus et atrophicus, keratosis lichenoides chronica, atrophicus, keratosis lichenoides chronica, prurigo nodularis, CTCL.prurigo nodularis, CTCL.

Positive effects in urticaria pigmentosa, Positive effects in urticaria pigmentosa, granuloma annulare and rare sclerosing granuloma annulare and rare sclerosing skin disease group.skin disease group.

No effect in chronic urticaria group.No effect in chronic urticaria group.