Indian Journal of Dermatology
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SHORT COMMUNICATION
Year : 2006  |  Volume : 51  |  Issue : 1  |  Page : 36-38
Evaluation of puva therapy in palmoplantar dermatoses


Department of Dermatology, Dayanand Medical College & Hospital, Ludhiana (Punjab), India

Correspondence Address:
Aman Dua
4, Officers Colony, Rose Garden,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.25187

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  Abstract 

BACKGROUND: Palmoplantar dermatoses often show therapeutic problem. PUVA therapy represents an effective remedy for refractory dermatoses. PURPOSE: To evaluate the response of palmoplantar dermatoses to PUVA therapy. METHODS: A propsective study undertaken on 50 patients from the Outpatients Department of Dermatology in Dayanand Medical College and Hospital, Ludhiana to study the effect of PUVA therapy in plamoplantar dermatoses. Out of the total of 50 patients, 26 patients (52%) had chronic plaque psoriasis, 19 patients (38%) had vitiligo (acrofacial variety) and 5 patients (10%) had lichen planus. Each patient was given PUVA therapy 3 times of week on alternate days for 6-12 months or remission whichever was earlier and then followed up for 6 months. RESULTS: About 62.5% patients of psoriasis, 55.5% of vitiligo and 60% of lichen planus showed improvement. Main side effects were nausea and erythema (20%). PUVA Therapy had to be stopped in one patient due to flaring of psoriasis. After six months of follow-up, 60% of patients were maintained in remission in psoriasis; none of the patients of vitiligo showed any loss of pigmentation; and, all the patients who showed improvement in lichen planus were maintained in remission. CONCLUSION: PUVA Therapy is a successful treatment for plamoplantar dermatoses like psoriasis, vitiligo and lichen planus. LIMITATION: Open study having no control and small sample size.


Keywords: PUVA therapy, Plamoplantar dermatoses, Psoriasis, Vitiligo, Acrofacial, Lichen planus


How to cite this article:
Dogra A, Dua A, Chopra S C. Evaluation of puva therapy in palmoplantar dermatoses. Indian J Dermatol 2006;51:36-8

How to cite this URL:
Dogra A, Dua A, Chopra S C. Evaluation of puva therapy in palmoplantar dermatoses. Indian J Dermatol [serial online] 2006 [cited 2019 Jul 19];51:36-8. Available from: http://www.e-ijd.org/text.asp?2006/51/1/36/25187



  Introduction Top


PUVA (psoralen and ultra violet light A) therapy involves the therapeutic use of non ionizing radiation, i.e. UVA in combination with a photosensitizing chemical. psoralen (methoxasoralen or trioxsalen). These two compounds are effective photosensitizers and are the agents most extensively used. Photosensitization selectively inhibits epidermal DNA synthesis by forming cycloadditive DNA products without a proportionate inhibition of epidermal function. These psoralen - DNA cross links cause a decrease in the rate of action of these agents. It also has a direct effect on cutaneous immune system.[1] PUVA therapy has emerged as a successful modality of treatment with minimal side effects in dermatoses like vitiligo[2] and keratodermas like psoriasis and lichen planus[3] that have been traditionally regarded as being resistant to therapy.[4]


  Materials and Methods Top


The study was conducted on 50 patients selected from the Outpatients Department of Dermatology, Dayanand Medical College Hospital, Ludhiana.

Inclusion Criteria

a) Palmoplantar keratodermas-psoriasis and lichen planus.

b) Plamoplantar vitiligo.

Exclusion Criteria

History of hypersensitivity reactions; photosensitive diseases like SLE, porphyrias, etc.; pregnancy, aphakia, age less than 10 years; immunosoppre-ssion; significant hepatic and renal insufficiency; cataract; pemphigus; pemphigoid, etc.

The patients were administered methoxsalen 0.5-0.7 mg/kg body weight (mean 0.6 mg/kg). The drug was administered with low fat food or milk, 90-120 minutes before each dose of UVA radiation in the "hand and foot" PUVA unit. The initial exposure various depending upon skin type or minimum phototoxic dose (MPD). In the Indian skin, the minimal erythema dose (MED) cannot be determined regularly and hence, it is recommended that the patient should be exposed to 3.5-4 J/cm2 following oral psoralen. Increments may be 0.5-1 J/cm2 for each sitting of oral PUVA and no more increments were given after 8-10 J/cm2 was reached. [Table - 1]

Frequency of UVA exposure: 2-3 times per week

Exposure time was calculated as follows:

Exposure time = x 16.7

The exposure time and total energy delivered were recorded and increased with each treatment. During treatment and followup it, the patients were asked to wear UV blocking sunglasses for 12 hours to prevent premature cataract.

Patients were given treatment three times a week on alternate day for 6-12 months or till remission, whichever was earlier and then followed up for six months.

Vitiligo

Initial examination: Following things were recorded.

Sites, number of patches, size: maximum vertical length (cm) x maximum horizontal length (cm) = area (cm2)

Follow-up: Repigmentation was graded on follow-up as percentage of original area and side effects were noted.

Palmoplantar Keratodermas

Initial examination: The following things were recorded.

Sites, number of patches, size: Maximum vertical length (cm) x maximum horizontal length (cm) - area (cm2)

The areas were graded depending upon the following criteria: Erythema, thickening, fissuring, scaling. They were classified as mild, moderate and severe (grades I, II, III respectively).

Each of the grades of each criteria was given one point and all the points were added up at each visit to note the score.

Follow-up: Grading was done on follow-up as per [Table - 2] and side effects were noted.


  Results Top


Out of a total of 50 patients, 26 had psoriasis, 19 had vitiligo and 5 lichen planus.

Psoriasis

Among the 26 patients, 18 were males and 8 were females. Maximum number of patients i.e. 14 patients (53.84%) required between 11-20 sittings [Table - 1]. Patients with duration of disease less than 2 years required less number of sittings as compared to patients with duration of disease more than 2 years. Fifteen patients (62.5%) showed some improvement wereas 9 patients showed no improvement [Table - 2]. Nausea and erythema (20%) were the commonest side effects [Table - 3].

Vitiligo

Out of the 19 patients, 10 were male s and 9 females. Mzximum number of patients i.e. 5 patients (26.33%) requir3ed between 71-80 sittings [Table - 1]. Duration of disease had no bearing no number of sittings. Ten patients (55.5%) showed some improvement whereas 8 patients showed no improvement [Table - 2]. Erythema (55.5%) was the commonest side effect [Table - 3].

Lichen Planus

Out of 5 patients, 1 was male and 4 were females. Maximum number of patients i.e. 3 patients (60%) required between 11-20 sittings [Table - 1]. Three patients (60%) showed some impovement whereas 2 patients showed no improvement [Table - 2]. Only 2 patients showed side effects in the form of nausea and erythema [Table - 3].


  Discussion Top


Psoriasis

The average number of sittings required to show some improvement was 7 while the average number of sittings to achieve remission was 27. This is in accordance with the results reported by Morrison et al,[4] who reportted an average of 14-22 treatments. The number of sittings required to achieve remission was more than that of generalized body psoriasis because the skin over hends and feet is thicker and more prone to koebnerization. In our study, we found that 15 patients (62.5%) showed some improvement whereas 9 patients (37.5% of cases of palmoplantar psoriasis. After 6 months of follow-up, out of the 15 patients who showed improvement, 6 patients (40%) reported worsening of symptoms.

Vitiligo

Out of the 19 patients, 5 patients (26.31%) required sittings in the range of 71-80 to achieve some improvement. This is in accordance with results reported by Parrish et al 6. In our study, we found that 10 patients (55.55%) showed some improvement in the form of repigmentation. Almost similar results were reported by Lerner et al .[7] After 6 months of follow-up, out of the 10 patients who showed imporvement, 8 patients (80%) showed no loss of pigmentation.

Lichen Planus

A majority of patients i.e. 3 patients (60%) required sittings in between 11-20. Average number of sittings required to achieve remission was 29. This is in accordance with results reported by Ortonne et al[8], who reported an average of 31 sittings. We found that 3 patients (60%) showed improvement. The results are less impressive than those of Ortonne et al[8] as the latter used PUVA in diffuse lichen planus not restricted to hands and feet. After six months of follow-up, 3 patients who showed improvement did not report any worsening of symptoms.


  Conclusion Top


Although the study group was small, it is concluded that PUVA therapy is a good form of treatment for patients with limited involvement ans small duration of disease in psoriasis while palliative for those with more severe disease with longer duration. It is a good form of therapy for acrofacial variety of vitiligo which is, as such, very resistant to treatment. Although complete repigmentation was not obtained, the results were permanent. It is a good form of therapy in palmoplantar lesions which are, as such rare manifestations lichen planus. Further sides with more number of patients with whole body PUVA unit need to be taken up for future evaluation.



 
  References Top

1.Friendmann PS. Disappearance of epidermal Langerhan cells during PUVA therapy. Br J Dermatol 1981; 105; 219-21.  Back to cited text no. 1    
2.El Mofty AM. Vitiligo and psoralens. Oxford, Pergamon Press. 1968; 1147-95.  Back to cited text no. 2    
3.Gonzales E, Momtaz TK, Freedman S. Bilateral comparison of generalized lichen planus treated with psoralens and ultraviolet A. J Am Acad Dermatol 1984; 10: 958-61.  Back to cited text no. 3    
4.Morrison WL, Parrish JA, Fitzpatrick TB. Oral methaxosalen Photochemotherapy of recalcitrant dermatoses of palms and soles. Br J Dermatol 1978; 99: 297-302.  Back to cited text no. 4    
5.Lawrence CM, Marks J, Parker S. Comparision of PUVA etretinate and PUVA placebo for palmoplantar psoriasis. Br J Dermatol 1984; 110: 221-6.  Back to cited text no. 5    
6.Parrish JA, Fitzpatrick TB, Shea C, Pathak MA. Photochemotherapy of vitiligo. Arch Dermatol 1976; 112: 1531-4.  Back to cited text no. 6  [PUBMED]  
7.Lerner AB, Denten RC, Fitzpatrick TB. Clinical and experimental studies with 8-methoxy psoralen in vitiligo. J Invest Dermatol 1952; 299-314.  Back to cited text no. 7    
8.Ortonne JP, Thiovolet J, Sannwald C. Oral photochemotherapy in the treatment of lichen planus. Br. J Dermatol 1978; 99: 77-87.  Back to cited text no. 8    


    Tables

[Table - 1], [Table - 2], [Table - 3]



 

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   Abstract
   Introduction
   Materials and Me...
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