Indian Journal of Dermatology
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SHORT COMMUNICATION
Year : 2005  |  Volume : 50  |  Issue : 4  |  Page : 212-215
Puva therapy in chronic actinic dermatitis: A preliminary study.


Department of Dermatology, SID and Leprosy, Govt. Medical College and associated SMHSHospital Srinagar, Kashmir,J&K, India

Correspondence Address:
Qazi Masood
House no: 214 Gole market, Karannagar, Srinagar Kashmir
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Five patients with biopsy documented chronic actinic dermatitis were treated with PUVA therapy during spring and early summer. Out of these, only one patient remains in remission till date while the other patients relapsed after an average duration of two months.


Keywords: Chronic actinic dermatitis (CAD), PUVA therapy


How to cite this article:
Masood Q, Sameem F, Hassan I, Khan D, Majid I, Bhat T, Singh G. Puva therapy in chronic actinic dermatitis: A preliminary study. Indian J Dermatol 2005;50:212-5

How to cite this URL:
Masood Q, Sameem F, Hassan I, Khan D, Majid I, Bhat T, Singh G. Puva therapy in chronic actinic dermatitis: A preliminary study. Indian J Dermatol [serial online] 2005 [cited 2020 Aug 5];50:212-5. Available from: http://www.e-ijd.org/text.asp?2005/50/4/212/19747



   Introduction Top


Chronic actinic dermatitis [CAD] is an idiopathic photodermatosis defined as a persistent eruption of generally eczematous rash possibly associated with infiltrated papules and plaques predominantly affecting the exposed skin and a histopathology consistent with chronic eczema with or without lymphoma- like changes associated with a reduction in minimal erythema dose (MED) to UVB & UVA or visible light.[1] The treatment is usually only partially effective and includes avoidance of UVR, broad-spectrum sunscreens, azathioprine, oral or topical steroids and PUVA therapy. Photo chemotherapy with ultraviolet-A light (PUVA) has been tried in many centers with varied results. A pilot study is being presented in the paper.


   Materials and methods Top


Five patients of chronic actinic dermatitis (biopsy documented) were enrolled for the present study. The patients were admitted in SMHS hospital (associated teaching hospital of Govt. Medical college Srinagar Kashmir) in early spring 2003.The acute exacerabation, in each was first controlled by strict sun avoidance in a dark room, antihistaminics and injectable steroids. A complete history of the primary disease was taken with special emphasis on the total duration of illness, the nature of the first episode, any associated medical or dermatological disorder, any history of drug intake and also the previous therapies taken by the patient along with response to each and screening for autoimmune disease was done. Any contraindication to PUVA therapy was ruled by laboratory evaluation. This included a complete hemogram, kidney and liver function tests, urine exam, chest skiagram and ECG. Special emphasis was laid on ophthalmological screening. After these preliminary investigations, patients were started on PUVA therapy. They were administered oral 8-methoxypsoralen [8-MOP] 0.6 mgl per kg body weight on alternate days at 8 o'clock in the morning followed 2 hrs later by UV exposure in Waldman's whole body UV chamber (Germany). Strict eye care and genital protection was followed. The exposure was followed by re-entry into dark room for first 2 weeks. PUVA therapy was confined to the light exposed areas with the patient wearing a short-sleeved shirt and trousers during PUVA exposure. The initial and incremental UVA dose was given according to the protocol as shown in [Table - 1][2] Rigorous photoprotection of eyes by UV opaque goggles was followed in the patient with cataract.[2],[3]

A regulated increase in exposure to sunlight was done and the dose of steroids was gradually decreased. Topical steroids were avoided as far as possible due to occlusion folliculitis. At the end of therapy, the patients were discharged and advised weekly maintenance PUVA therapy (UVA- 10J/ sq.cm). The response was judged in terms of improvement in erythema, induration, scaling, lichenification, pigmentation and pruritus. A post treatment biopsy was done for comparison. The above schedule was made flexible in case of slow response. Any acute exacerbation was managed by increasing the dose of oral steroids.

Informed consent was obtained in all cases. Phototesting and photopatch testing was not possible in our setting. Patients with light eczema were excluded.


   Results and analysis Top


Five patients of chronic actinic dermatitis admitted in our hospital between March 2003 and July 2003 were included in the present study. The patients (all males) were farmers by occupation with an average age of 60 years (55-­65 years age range). The average duration of disease in these patients was 6 years (range 3 to 11 years). In one patient, it started as an episode of photo­allergic drug rash, in 3 as air borne contact dermatitis, in 2 as photo aggravated atopic eczema. Four patients had hypertension, one had diabetes mellitus, one had chronic obstructive pulmonary disease [COPD]. Two patients had taken photosensitive drugs (NSAIDS, sulfonylureas). Previous therapies taken by the patients were topical steroids (5), oral/injectable steroids (5), hydroxychloroquine sulfate (1), azathioprine (1) with either minimal response or a good response followed by prompt relapse on discontinuation. The routine investigations revealed steroid induced diabetes in 1, subcapsular cataract in 3, ischemic heart disease in 1 and COPD in 1 patient.

The patients were put on thrice weekly PUVA followed by maintenance on weekly PUVA. The average duration of PUVA therapy was 4 weeks. The average cunnnulative dose of UVA was 45 J/sq.cm till completion of active therapy. Al patients responded and went into clinical remission by 3 weeks and there was a global improvement in all the pararneters of erythema, scaling, pruritus, pigmentation, lichenification and infiltration. The patients were discharged at 4 weeks and returned once a week for maintenance PUVA.

All patients remained in remission till 8 weeks after discharge. Four patients developed relapse manifested by increasing degrees of pruritus, erythema and scaling. One patient was lost to follow up. One patient was irregular in coming for weekly PUVA. In those patients who developed exacerbation, it was sought to be controlled initially by reintroducing oral steroids or adding topical steroids. In two patients PUVA had to be discontinued as there was a relapse with greater severity. However the infiltration cleared completely in all and the disease responded rapidly and to a minimal dose of steroids. These two patients had restarted the use of photosensitizing drugs after discharge from the hospital. Till date the one patient who remains in remission is coming for follow-up regularly. He is doing well with no steroids and has now been put on fortnightly PUVA.


   Discussion Top


A preliminary study on five patients of biopsy documented CAD was designed. Besides other investigations, ophthalmological examination was done.[3],[4] In our study, the age range of patients was from 55-65 years consistent with reports of this being a dermatosis of middle aged or elderly. All the patients were males and engaged in fanning activities with a greater likelihood of exposure to UV rays. The patients had no family history of this dennatosis and the collagen profile was normal. The primary episode in most was suggestive of persistent light reactivity as it was in the form of acute photo allergic contact dermatitis or drug photosensitivity. Among the associated diseases were diabetes mellitus, hypertension, COPD, ischemic heart disease and cataract. The concomitant photosensitizing drug intake in two patients against advice resulted in a poorer response in these patients.

The remarkable improvement seen in all the patients at the end of thrice weekly PUVA supported the effect of PUVA in CAD. There was disappearance of pruritus, erythema, scaling and infiltration in spite of exposure to sunlight and tapering off of steroids. However the relapse seen at the end of 8 weeks in 4 patients was suggestive of incomplete desensitization or wearing off of the beneficial effect on discontinuation. This observation was confounded by factors of irregular follow up, use of photosensitizing drugs and unregulated exposure to mid-day sunlight.

Chronic photosensitivity was first reported to respond to graded UV exposure in 1938 by Hurst by a process of desensitization.[5] PUVA therapy has been tried in severely incapacitated patients of polymorphous light reaction(PMLE), solar urticaria, actinic prurigo and CAD. [6],[7],[8]

In the study carried out by Honig B, et al[9], 90% of patients with chronic photosensitive eczema responded successfully to PUVA desensitization by clearance of the eruption and induction of tolerance. More than 30 patients so treated underwent a spontaneous remission after 2 to 7 years of treatment. PUVA therapy was initially combined with high dose of oral steroids and PUVA was given 3 to 4 times per week . The patients were discharged after the initial two weeks of hospitalization and PUVA therapy was completed with tapering of steroids at the same time. Maintenance was given once weekly during summer and twice monthly during winter with mild adjustments to control the mild residual photosensitivity.

In a study by Hindson C, et al[2], the protocol for graded exposure to UVA was suggested. PUVA therapy was given twice weekly along with the prescription of topical steroids for any acute exacerbation. A good response was elicited at the end of the study in seven patients with a long history of photosensitivity and remission was maintained for a long time.

The response of photodermatosis to PUVA therapy may partly be due to increased pigmentation as also hyperplasia of the epidermis and modulation of cutaneus immune functions. PUVA preventive treatment protects only temporarily but regularly repeated sun exposure can maintain protection. Side effects observed during therapy were nausea (4), vomiting (1), persistent pruritus and stinging sensation, acute exacerbation in the initial phase (controlled by increasing the steroid dose) and herpes labialis. However no deterioration of cataract was seen in any patient.

This study was designed as a preliminary model for treatment of Kashmiri patients of CAD by PUVA. Such a treatment modality had never been tried before in our center. In spite of the unflattering statistics, it is intended to enroll further patients for this modality in the future taking special care to prevent the menace of poor patient compliance and use of photo allergic drugs. In conclusion, the PUVA therapy for CAD was successful in only one patient in inducing a long lasting remission. In the other patients, the problems of drug compliance and use of photoallergic drugs resulted in relapse at the end of two weeks. A larger study is needed to refute or confirm the finding of the present study.

 
   References Top

1.Hawk JLM, Magnus IA:Chronic Actinic Dermatitis -an idiopathic photosensitivity syndrome including actinic reticuloid and photosensitive eczema.Br J Dermatol 1979; 101 (supp117):24.   Back to cited text no. 1    
2.Hindson C , Spiro J , Downey A .PUVA therapy of chronic actinic dermatitis. Br J Dermatol 1985;113 :157- 60.  Back to cited text no. 2  [PUBMED]  
3.Cloud TM , Hakim R ,Griffin C . Photosensitisation of the eye with methoxsalen. Arch Ophthalmol 1961; 66:689-94.  Back to cited text no. 3    
4.Parrish JA, Chylack LJ , Woehler ME, et al . Dermatological and ocular examinations in rabbits chronically photosensitized with methoxsalen . J Invest Dermatol 1979 ; 73 : 56-8.  Back to cited text no. 4    
5.Hurst A . Light sensitization cured by progressive light desensitization . Practitioner 1938; 141 :220-1.   Back to cited text no. 5    
6.Gschnait F , Honigsmann H, Brenner W et al . Induction ofUV light tolerance by PUVA in patients with PMLE . Br J Dennat 1978; 99:293-5.  Back to cited text no. 6    
7.Farr PM , Diffey BL . Treatment of actinic prurigo with PUVA: mechanism of action. Br J Dermatol 1989 ; 120 : 411-8.   Back to cited text no. 7  [PUBMED]  
8.Morison WL , White HAD , Gonzalez E , et al. Oral methoxsalen photochemotherapy of uncommon photodermatoses . Arch Derm Venerol (Stockh) 1979 ; 59 :366-8.   Back to cited text no. 8    
9.Honig B , Morison WL , Karp D . Photo chemotherapy beyond psoriasis. J Am Acad Dermatol1994 ; 11 :775-90.   Back to cited text no. 9    


Tables

[Table - 1]



 

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    Abstract
    Introduction
    Materials and me...
    Results and analysis
    Discussion
    References
    Article Tables

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