Narrow-band UVB (311 nm) versus conventional broad-band UVB with and without dithranol in phototherapy for psoriasis

Narrow-band ultraviolet B is a useful and well-tolerated treatment for vitiligo

BACKGROUND

The treatment of vitiligo remains a challenge.

OBJECTIVE

The purpose of this article is to review our results and experience with narrow-band ultraviolet (UV) B phototherapy for vitiligo.

METHODS

This is a retrospective analysis of our experience and results with patients with vitiligo who were treated with narrow-band UVB between November 1998 and November 1999. Narrow-band UVB phototherapy was given as monotherapy 3 times a week. The starting dose was 280 mJ/cm(2), with 15% dose increments at each subsequent treatment.

RESULTS

Seven patients were able to be evaluated for the purposes of this analysis. Their ages ranged from 19 to 59 years (mean, 37.6 years). Three patients had Fitzpatrick skin phototype IV and V, and 4 had phototypes II and III. Five of the 7 patients achieved more than 75% repigmentation with a mean of 19 treatments; the mean duration of disease was 13 months. The remaining two patients had 50% and 40% repigmentation after 46 and 48 treatments, respectively. Their mean duration of disease was 132 months. Adverse effects were mild erythema and pruritus.

CONCLUSION

This treatment protocol resulted in rapid repigmentation in many patients, including those with skin phototypes IV and V. In accordance with previous studies, this report indicates that narrow-band UVB is a useful and well-tolerated therapy for vitiligo.

Dermatology day care treatment centres

Day care treatment centres provide the best solution for the treatment of most patients with psoriasis. The centre is not only ideal for treatment but has other roles, such as education of patients and nurses. The specialist dermatology nurse is the key to success. Out patient treatment of psoriasis is less expensive than in patient treatment. The development of a treatment centre should be seen as an additional facility and not as a substitute for in patient beds.

Differences in efficacy between intention-to-treat and per-protocol analyses for patients with psoriasis vulgaris and atopic dermatitis: clinical and pharmacoeconomic implications

BACKGROUND

Pharmacoeconomic outcome research is based on three criteria: (i) evaluation of objective therapeutic effects; (ii) quality of life; and (iii) treatment costs. Evaluation of therapeutic effect is mainly based on the results of clinical trials using objective clinical measures, e.g: Psoriasis Area and Severity Index (PASI) (score for psoriasis vulgaris) and the Severity Scoring of Atopic Dermatitis (SCORAD) (score for atopic dermatitis). In most studies, only results for a treatment-optimized subpopulation (patients treated according to the protocol) are presented in publications. The relevance of such data for daily routine therapy is doubtful.

OBJECTIVES

Our purpose was to investigate the expected loss of effectiveness of switching from a clinical trial to daily routine therapy for the synchronous application of narrow-band ultraviolet (UV) B phototherapy (311 nm) and bathing in 10% Dead Sea salt solution (synchronous balneophototherapy) for patients with psoriasis vulgaris and atopic dermatitis.

METHODS

We conducted a multicentre, uncontrolled observational study of outpatients. To achieve data for 'clinical trial' and 'daily routine' situations, two populations were compared: (i) all patients strictly treated according to the protocol (ATP) with no protocol deviations (data published in clinical trials), and (ii) all patients participating in the study who received active treatment at least once, despite treatment irregularities, non-compliance, early withdrawal or other protocol violations [intention-to-treat-population (ITT), model for 'daily routine'].

RESULTS

A total of 2526 patients were included in the ITT analysis for psoriasis vulgaris (n = 487 for atopic dermatitis), of which 818 patients could be analysed according to protocol (n = 104 for atopic dermatitis). Striking differences in the therapeutic effect between both groups (ITT and ATP) were found using relative PASI and SCORAD score improvement: 11% (57% 'daily routine' vs. 68% in 'clinical trial') for psoriasis vulgaris and 16% (39% 'daily routine' vs. 55% 'clinical trial') for atopic dermatitis. The main reasons for excluding patients from the 'clinical trial' group were early study withdrawal in 29% (atopic dermatitis, 47%) of patients and fewer treatments per week than planned in the protocol in 24% (atopic dermatitis, 52%).

CONCLUSIONS

Our data clearly indicate that for the prediction of the therapeutic effect for daily routine therapy the ITT data appear to be more relevant than the ATP results (i.e. those presented in clinical trials). Although these data are only a first step for evaluating the 'real' therapeutic effect of a treatment modality in daily routine, they seem to support the requirements for ITT analyses in efficacy studies and demonstrate the necessity of ITT data for pharmacoeconomic evaluation.

Evaluation of a multicentre study of synchronous application of narrowband ultraviolet B phototherapy (TL-01) and bathing in Dead Sea salt solution for psoriasis vulgaris

The synchronous application of narrowband UVB phototherapy with 311 nm lamps (Philips TL-01) and bathing in Dead Sea salt solution was evaluated in a multicentre trial (n = 60) in outpatients suffering from psoriasis vulgaris. The study design consisted of an initial therapy phase of up to 35 treatments (three to five times a week) followed by maintenance therapy with up to 35 further applications (once or twice a week). Evaluation was performed separately for patients in according-to-protocol (ATP) (n = 280) and intention-to-treat (ITT) (n = 692) groups. An overall significant improvement of the Psoriasis Area and Severity Index (PASI) score (P < 0.05) could be shown for both groups during initial therapy with 71.4% improvement for ATP and 61% for ITT patients. The mean PASI for ATP (values for ITT in parentheses) was 17.7 (18.6) at baseline, 9.5 (10.7) after 20 applications and 5.2 (7.4) at the end of initial therapy. On average, ATP patients received 3.9 (3.5) applications per week with a cumulative irradiation dose of 19.5 J cm-2 (16.2 J cm-2). The most frequent side-effect was erythema, observed in 8.7% of the patients. Subjective evaluation of the therapy by the patients (n = 168) was excellent. Seventy-nine per cent of patients preferred the new treatment strategy in comparison with other previous therapies and 88% regarded this therapy as pleasant and comfortable. In conclusion, we could demonstrate a significant effect of therapy in both the ATP and the ITT groups for this new treatment system which imitates, as far as possible, the Dead Sea climatic conditions, with no severe side-effects and a high acceptance by the patients.

Combination phototherapy of psoriasis with narrow-band UVB irradiation and topical tazarotene gel

BACKGROUND

Narrow-band UVB (311 nm) phototherapy offering an emission spectrum closely conforming to the peak of the action spectrum for clearing psoriasis has significantly improved phototherapy for psoriasis. Because the majority of the commonly used topical therapies in treatment of psoriasis have limitations, a need for new topical agents remains. Tazarotene has been shown to be efficacious in plaque-type psoriasis. Combination of narrow-band UVB with topical agents has been shown to enhance efficacy of both treatment modalities.

OBJECTIVE

We attempted to evaluate the efficacy of narrow-band UVB phototherapy in combination with topical tazarotene.

METHODS

Ten patients with stable plaque psoriasis were treated with narrow-band UVB. In addition, topical tazarotene 0.05% was applied once daily to one side of the body. The follow-up period was 4 weeks. Efficacy was assessed separately for both body halves by means of a modified Psoriasis Area and Severity Index (PASI).

RESULTS

Both treatment modalities notably reduced the PASI scores with values being significantly lower in skin areas treated with narrow-band UVB phototherapy in combination with topical tazarotene.

CONCLUSION

The addition of tazarotene to narrow-band UVB phototherapy promotes more effective, faster clearing of psoriasis compared with UVB (311 nm) monotherapy.

Optimized UVB treatment of psoriasis: a controlled, left-right comparison trial

In a randomized, controlled, left-right comparison study, 20 patients with chronic plaque psoriasis were treated with UVB. One side of the body received UVB in a conventional regimen with fixed dose increments, the other side was given UVB doses according to measurements of skin pigmentation. Skin pigmentation was quantified by the skin reflectance technique. The relationship between skin pigmentation and sensitivity to UV radiation was used to optimize and individualize the initial UVB exposure dose. Clinical outcome, initial, final and cumulative UVB doses, time to 50% reduction in PASI score, and side-effects were compared. The consequence of the optimization of the UVB doses with a skin reflectance meter was that the initial UVB dose was significantly higher than in the conventional UVB regimen. PASI scoring demonstrated a more rapid improvement during the first 2 weeks of treatment on the half body receiving the optimized treatment compared to the other side (P < 0.05). This new technique offers the same therapeutical advantages and security as a dose regimen guided by minimal erythema dose testing. However, measurement of skin pigmentation by skin reflectance is a quick method which can be operated easily by nurses.

Phototherapy and photochemotherapy: an update

Three types of phototherapy and 2 forms of photochemotherapy are now available for treatment of more than 40 diseases of the skin. Broadband ultraviolet B (UVB) phototherapy and oral psoralen photochemotherapy (PUVA) therapy are most widely available while there has been increased interest in topical PUVA therapy. Narrow-band UVB phototherapy and UVA-1 phototherapy offer potential for the future.

A randomized comparison of narrow-band TL-01 phototherapy and PUVA photochemotherapy for psoriasis

BACKGROUND

Although PUVA treatment of psoriasis is more effective than conventional or broad-band UVB phototherapy, two small studies have suggested that narrow-band or TL-01 phototherapy may have a therapeutic effect equal to PUVA. If confirmed, this would be of considerable importance as TL-01 therapy is likely to be considerably safer in the long term than PUVA.

OBJECTIVE

The purpose of this study was to compare PUVA with narrow-band (TL-01) phototherapy in psoriasis.

METHODS

We studied 100 patients with plaque-type psoriasis who were randomly allocated to twice-weekly treatment with PUVA or narrow-band UVB.

RESULTS

Clearance of psoriasis was achieved in a significantly greater proportion of patients treated with PUVA (84%) than with TL-01 (63%) (P =.018), and with significantly fewer treatments (median number of treatments for clearance with PUVA, 16.7; with TL-01, 25.3; P =.001). Only 12% of those treated with TL-01 were clear of psoriasis 6 months after finishing treatment compared with 35% for PUVA (P =.002).

CONCLUSION

When given twice weekly, PUVA is more effective for psoriasis than narrow-band UVB phototherapy.

Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris

BACKGROUND

Narrow-band UVB (NB-UVB) is a new phototherapy option for psoriasis. Action spectrum studies previously done with different UVB wavelengths suggest that suberythemogenic doses of NB-UVB could be highly effective in treating psoriasis vulgaris. Even so, no comparative studies with suberythemogenic doses of NB versus conventional UVB have been performed previously.

OBJECTIVE

Our purpose was to compare conventional broad-band UVB (BB-UVB) with NB-UVB at suberythemogenic doses for the treatment of psoriasis vulgaris.

METHODS

Eleven patients were treated using a split-body approach for 6 weeks on a three-times-a-week basis. Outcomes were evaluated by means of Psoriasis Severity Index scores and quantitative histologic measures.

RESULTS

We were able to induce clinical clearing in 81.8% of patients after NB-UVB, but in only 9.1% of patients after BB-UVB (P < .01). Biopsy specimens obtained at the end of treatment revealed that keratin 16 staining was absent in 75% of patients on the NB side compared with none on the BB side, suggesting a reversal of regenerative epidermal hyperplasia by NB-UVB.

CONCLUSION

NB-UVB is superior to UVB-BB in reversing psoriasis at suberythemogenic doses when given three times per week. This schedule was well tolerated by all patients.

The efficacy of narrowband ultraviolet B phototherapy in psoriasis using objective and subjective outcome measures

The efficacy of narrowband ultraviolet B (UVB) was assessed in 100 consecutive patients with psoriasis by quantifying disease severity using objective (Psoriasis Area and Severity Index, PASI and Dermatologists Global Assessment, DGA) and subjective (Psoriasis Disability Index, PDI) measures. The median pretreatment PASI, DGA and PDI were 5.7 (interquartile range, IQR 4.5-8.35), 7 (IQR 6-9) and 42 (IQR 29-63.5), respectively. At 3 month follow-up, the PASI, DGA and PDI had fallen to 2.7 (IQR 1.1-3.5), 3 (IQR 2-5) and 30 (IQR 21-50.5), respectively (P < 0.001). A small group of patients continued to score highly on their PDI despite being clinically clear or having minimal disease, possibly representing chronic disability behaviour. Patients exhibiting this may require more intensive supervision. In most patients, symptoms of itch and pain improved or disappeared (70% and 75%, respectively). Side-effects were reported in 18%. Narrowband UVB phototherapy is safe and effective for psoriasis. Symptoms and subjective quality of life measures improved significantly. Both objective and subjective measures should be used when evaluating the efficacy of a treatment for psoriasis.

The effectiveness of modified ingram therapy compared with severity of psoriasis

To treat cases of psoriasis, various modifications of the original Ingram method were tested for increased effectiveness and minimized side reactions. Our modified method consists of 0.1-0.5% anthralin ointment application and selective UVB phototherapy with adjunctive warm water bath and the application of emollients. The object of this study was to evaluate the effectiveness and duration of remission in response to our modified Ingram method and compare the data with the severity of psoriasis. The clearing rate was higher and the failure rate was lower in the moderate group. The number of occasions on which therapy was used and the duration of this therapy were greater in the severe group, but there were no significant differences except for the number of occasions of therapy to the trunk. Fifty-eight percent of the moderate group did not relapse in more than one year, but 63% of the severe group relapsed within six months. The results of this study showed that the modified Ingram regimen is an effective therapeutic modality in psoriasis, especially in the moderate group.

Comparison of phototherapy with near vs. far erythemogenic doses of narrow-band ultraviolet B in patients with psoriasis

The therapeutic effectiveness of radiation from a 311 nm ultraviolet B (UVB) lamp (Philips TL-01) in a near vs. far erythemogenic therapy regimen was investigated in 13 patients with widespread, symmetrically distributed psoriasis. The patients received UV therapy starting with 70% of the 311 nm minimal erythema dose (MED) on one randomly chosen half of the body and 35% of the 311 nm MED on the other half. Therapy was given three to five times a week, and the UVB dose in both regimens was increased simultaneously in the same relation. For the 11 patients completing the study, the mean psoriasis area and severity index (PASI) score for the near vs. far erythemogenic treatment side was 21.2 vs. 18.5 before therapy (Wilcoxon's test, not significant), 11.8 vs. 14.4 at week 1 (P = 0.003), 8.2 vs. 12.0 at week 2 (P = 0.004), and 6.6 vs. 15.6 at week 3 (P = 0.005). After 3 weeks, a satisfactory response (i.e. improvement of the initial PASI score by more than 75%) was observed in six of 11 patients on the near erythemogenic treatment side vs. three of 11 patients on the far erythemogenic side. However, the definitive median total number of treatments needed to achieve a satisfactory therapy response on the near vs. far erythemogenic sides was 12 vs. 16 (P = 0.022), whereas the definitive median cumulative UV dose was 14.0 vs. 9.1 J/cm2 (P = 0.088), respectively. These results suggest that near erythemogenic 311 nm UVB therapy may clear psoriasis faster than far erythemogenic therapy but that the latter regimen may be equally effective as it requires slightly more treatment sessions at a lower (and possibly less carcinogenic) cumulative UV dose.

Systemic treatment of severe psoriasis

Severe psoriasis presents a difficult therapeutic challenge. Some modalities such as synthetic retinoids, phototherapy and methotrexate have been available for many years and need reappraisal, cyclosporin has only recently become available and requires careful administration. In this article we focus on the therapeutic modalities available to the dermatologist in Australia.

Recent developments in the treatment of atopic eczema

Atopic eczema remains a therapeutic challenge. However, new developments in the understanding of the pathogenesis of this complex disease have prompted new therapeutic strategies. This review focuses on recently described treatment modalities for atopic eczema that are currently available or under investigation. The effectiveness of phototherapy, cytokines, and immunosuppressive drugs is evaluated. In addition, some new and promising but still experimental approaches are discussed.

Recent advances in the treatment of psoriasis

We have seen great progress in the past decade in our understanding of the pathogenesis of psoriasis. The fruits of this knowledge are being realized in many of the exciting immunologic therapies currently in development. The potential for astute clinical observation to produce effective therapies and to change the direction of research has been proven in the past and still remains as an avenue for the future. Although individual treatments were discussed in this article, combination therapy is likely to continue to play a major role. Additionally, because future therapeutic developments are not likely to be free of toxicity, rotational therapy may still be necessary. Many questions remain unanswered. Substantial progress is just beginning into the.

The phototumorigenic potential of broad-band (270-350 nm) and narrow-band (311-313 nm) phototherapy sources cannot be predicted by their edematogenic potential in hairless mouse skin

The new Philips TL01 narrow-band (311-313 nm) and conventional broad-band (e.g., Philips TL12; 270-350 nm) sources are effective for psoriasis phototherapy, for which treatment regimens are based on a predetermined minimal erythema dose. TL01 phototherapy treatment times are approximately half those with TL12 for psoriasis, whereas the cumulative exposure doses at clearing are similar. We compared the phototumorigenic potential of TL01 and TL12 radiation in mouse skin. Groups of albino Skh-1 hairless mice were exposed for 5 d/week at three dose levels. At each dose level, TL12 and TL01 doses were equally edematogenic. At each dose level, TL01 radiation was significantly more effective at producing first tumors of 1 mm in diameter and multiple tumors. At the lower two dose levels, TL01 radiation produced a significantly greater proportion of squamous cell carcinomas. This study demonstrates that TL01 radiation is more phototumorigenic than TL12 radiation at equally edematogenically weighted doses. This is in contrast with previous reports that edema production by polychromatic sources is predictive of their phototumorigenic effect in Skh-1 mice. The absolute cumulative TL12 dose needed to induce tumors was much less than that for TL01 radiation. The possibility of increased tumor risk with TL01 phototherapy should be considered but must be balanced against the high phototherapeutic efficacy of this source, short treatment times, and the low cumulative doses necessary for clearing of psoriasis.

Comparative potency of different UV sources in reducing the density and antigen-presenting capacity of Langerhans cells in C3H mice

Although broadband UV-B irradiation has been shown to induce selective immunosuppression in a variety of experimental systems, the wavelength dependence of the immunomodulation and the initial events in the skin remain unclear. In the present study three UV lamps were used at suberythermal doses on C3H mice: a conventional broadband UV-B source (270-350 nm), a narrowband UV-B source (311-312 nm) and a UV-A source (320-400 nm). Their effects on the photoisomerization of the naturally occurring trans-isomer of urocanic acid (UCA) to cis-UCA, on the density of Langerhans cells and on the ability of epidermal cells to stimulate allogeneic lymphocytes in the mixed skin lymphocyte reaction (MSLR) were ascertained. Broadband UV-B irradiation was more efficient than narrowband UV-B at reducing the density and function of Langerhans cells, while UV-A irradiation was least effective. These changes were most pronounced immediately following irradiation, were dose dependent and were only detected in UV-exposed areas of skin. There was a close correlation between the UV-induced reduction in Langerhans cell density and the formation of cis-UCA in the epidermis. This correlation was not detected between the reduction in the MSLR response following UV irradiation in vivo and cis-UCA formation.