Documentos de Académico
Documentos de Profesional
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Phototherapy
Jennifer A. Cafardi, Brian P. Pollack,
& Craig A. Elmets
DISEASES AMENABLE TO
PHOTOTHERAPY
Phototherapy and Psoriasis
BROADBAND UVB AND NARROWBAND UVB.
Both BB-UVB and NB-UVB have been employed
to treat psoriasis. Their presumptive mechanisms
of action in this disease include its effects on DNA,
antimicrobial actions which may alter the microbial
flora of the skin,111 induction of anti-inflammatory
and immunosuppressive cytokines,112114 augmentation of vitamin D levels,115116 alterations in antimicrobial peptides,116 and a reduction in C-reactive
protein.117
Clinical trials38 supporting the research findings41
that the wavelengths most effective at clearing psoriasis are in the range of 313 nm have led to broad
utilization of NB-UVB for psoriasis (eFig. 2370.1).
NB-UVB has thus become first-line therapy for
chronic plaque psoriasis, considered to be superior
to conventional broadband UVB with respect to
both clearing and remission times.38,118 The difference in efficacy may be related to more efficient
clearing of T cells by NB-UVB from the epidermis
and dermis of psoriatic plaques compared with
conventional broadband UVB.20 The endpoint of
phototherapy is complete clearance of all psoriatic
skin lesions. Psoriasis, however, is a chronic disease
and the remission induced by UVB phototherapy
is often short lived. In a randomized, prospective,
multicentered trial, investigators found that continuing UVB phototherapy after initial clearing contributes to the control of the disease and is justified
for many patients.119 In such maintenance therapy,
the frequency of UVB treatments is reduced while
maintaining the last dose given at the time of clearing. NB-UVB can be used safely in pregnancy and in
children.
Other agents (topical and oral) combined with
UVB phototherapy may clear psoriatic skin lesions
in a shorter period of time. Combined therapies
may thus allow for fewer treatments and potentially
less photoaging and other risks. Often combination
TARGETED PHOTOTHERAPY.
Targeted phototherapy using a monochromatic
308-nm excimer laser or monochromatic excimer
light is effective and safe for psoriasis. A large, multicenter study found that fewer patient visits were
required with targeted phototherapy compared to
conventional phototherapy.141 The use of monochromatic excimer compared to cream PUVA has
been found to have equivalent efficacy for palmoplantar psoriasis.142
PUVA PHOTOCHEMOTHERAPY.
Oral PUVA has been shown to consistently induce
remission of psoriasis in clinical studies.65,143,144
At least 75% improvement in PASI score can be
expected after 12 weeks of PUVA treatments in
60% of patients.143 In some studies, oral PUVA has
been observed to be more efficacious in clearing
plaque psoriasis than NB-UVB, and the duration of
remissions is more prolonged,144 while other studies
have found the two treatments to be comparable,
particularly when NB-UVB is used three times a
week.145148 It must be noted here that unlike drug
administration, the success of PUVA and phototherapy generally depends in large part on physiciandetermined patient-specific subtle modifications of
the regimen, such as the dose increments between
treatments, that optimize therapeutic response
while avoiding burns or other adverse effects.
Hence, the response to phototherapy may vary
greatly among studies and among practitioners.
Repeated exposures are required to clear PUVAresponsive diseases, with gradual dose increments
as pigmentation develops. Upon clearing, patients
are often transitioned to maintenance therapy, during which the frequency of treatments is gradually
reduced. There are various maintenance algorithms.
One regimen consists of 1 month of twice-weekly
treatments, at the last UVA dose used for clearing,
followed by another month of once-weekly exposures. Other protocols recommend maintenance
treatment only when the patient relapses rapidly.
This has the advantage of avoiding higher cumulative exposure and thus greater risk of long-term
side effects.
A combination of PUVA and methotrexate can
reduce the duration of treatment, number of exposures, and total UVA dose required for clearing and
is also effective in clearing patients unresponsive to
PUVA alone.149 This combination appears to be safe
if used during the clearing phase. However, longterm methotrexate, defined as 36 or more months
of use, in combination with PUVA may increase the
risk of lymphoma.87
The combination of cyclosporine with PUVA is not
recommended because of the greatly increased
risk of squamous cell carincoma.78 There are no
published clinical trials combining PUVA with the
biologic agents.
PUVA therapy is more efficacious when combined with a daily oral retinoid (etretinate, acitretin,
isotretinoin; 1 mg/kg), a treatment regimen that has
been referred to as RePUVA. The addition of an oral
retinoid can bring patients into remission, even if
they have not responded to PUVA alone.150 The oral
retinoid is typically administered 510 days before
initiating PUVA, and is continued throughout the
clearing phase. RePUVA often is able to reduce the
number of PUVA exposures by one-third and the
total cumulative UVA dose by more than one-half.
Oral retinoids when combined with PUVA have
been shown to reduce the risk of SCC by 30%, although it does not alter the incidence of BCC.79 The
mechanism of the synergistic action of retinoids
and PUVA is unknown, but has been postulated to
result in part from accelerated desquamation that
optimizes the optical properties of the skin.
Topical tazarotene gel 0.1% combined with oral
PUVA accelerates the response to treatment.151 This
may decrease exposure to UVA and thus the longterm hazards associated with PUVA therapy. Due
to the photosensitizing effect to tazarotene, it is
recommended PUVA therapy be initiated at slightly
lower doses than usual.136 The tazarotene plus PUVA
bath therapy is also clinically and statistically superior to vehicle plus PUVA bath therapy.152
The application of salicylic acid in petrolatum just
before PUVA therapy is not recommended as it may
hinder the penetration of UVA.153 When calcipotriol
is used with PUVA, it should not be applied within 2
hours of phototherapy.
TOPICAL AND BATH-PUVA FOR PSORIASIS.
Application of 8-MOP in creams, ointments, or
lotions followed by UVA irradiation is effective in
clearing psoriasis, but may result in nonuniform
distribution on the skin surface. This may induce
unpredictable phototoxic erythema reactions and
irregular patches of cosmetically unacceptable
hyperpigmentation. Furthermore, the application
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Phototherapy 345
Phototherapy of Vitiligo
PUVA and NB-UVB are two of the leading treatments for vitiligo. When employed for vitiligo,
NB-UVB is typically administered three times per
week.198 The earliest sign of response to therapy is
perifollicular repigmentation. Cosmetically acceptable treatment success, defined as greater
than or equal to 75% repigmentation, has been
achieved in 12.5%199 to over 75%200201 of patients.
Factors that predict how a patient will respond to
NB-UVB include Fitzpatrick skin phototype, the
areas treated,200206 and the type of vitiligo.202 There
does not appear to be an association between
response to treatment and patients sex, age, family history of vitiligo or the extent of body surface
area involved.205207 Patients who show early initial
repigmentation are more likely to have a higher
percentage of final repigmentation.199,205 Whether
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Phototherapy 347
Pruritis
Phototherapy is an option for the pruritus associated with chronic renal failure. About 80%90% of
patients improve within 25 weeks.255257 If symptoms recur, they commonly respond to retreatment
with UVB. For this disorder, phototherapy works on
a systemic level rather than locally, because BB-UVB
exposure to one-half of the body improves pruritus in both the exposed and unexposed sites.258
Some patients respond well to BB-UVB, and are less
responsive to NB-UVB.259
Phototherapy has been considered by some to be
the most effective treatment for cholestatic pruritus.260262 UVB phototherapy has also been combined with cholestyramine.263
PUVA has resulted in improvement in aquagenic
pruritus in a number of patients, but maintenance
treatments may be required.264266
Reports of successful treatment with NB-UVB
three times a week,267 UVA in combined with UVB,268
and PUVA269271 have been reported to improve the
pruritus associated with polycythemia vera.
NB-UVB and BB-UVB and PUVA have all been used
safely and effectively to treat eosinophilic folliculitis
in HIV-positive patients.272276
Photodermatoses
NB-UVB277279 and oral PUVA280281 is a useful method for preventing outbreaks of moderate-to-severe
polymorphous light eruption (PMLE). Hardening is
obtained by exposing the individual to low levels
of phototherapy while, at the same time, placing them prophylactically on oral corticosteroids
in order to prevent lesions. The mechanisms by
which phototherapy induces tolerance to sunlight
include thickening of the stratum corneum, hyperpigmentation and cutaneous immune modulation.
Although NB-UVB is currently used more commonly
than PUVA, PUVA has the advantage of a rapid and
intense pigment induction at relatively low UVA
doses that usually remain well below the threshold
for eliciting an outbreak. Approximately 10% of patients will develop typical PMLE lesions during the
initial phase of PUVA, but these usually disappear
with continued treatment. Phototherapy is typically initiated 1 month before the first anticipated
intense sun exposure, such as a sunny midwinter
Other Diseases
LICHEN PLANUS.
Narrowband UVB therapy has been used for recalcitrant lichen planus and is typically administered 3
times weekly on nonconsecutive days. A complete
response in 70% of patients has been reported after
an average time of 10 weeks.292294 Improvement in
the pruritus can be expected before disappearance
of skin lesions. Oral and topical PUVA295 are other
alternatives. In general, lichen planus tends to be
more resistant to PUVA than psoriasis when treated
with a similar schedule. A regimen of RePUVA may
accelerate clearing, but has been reported to cause
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