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Kassem R, Barzilai A, Pras E, Sizopoulou C, Pavlotsky F. Bath psoralen plus ultraviolet-A photochemotherapy for chronic graft-versus-host disease: a retrospective cohort study. Int J Dermatol 2023; 62:1261-1265. [PMID: 37568259 DOI: 10.1111/ijd.16806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/20/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease is a severe complication of allogeneic stem cell and bone marrow transplantation. First-line immunosuppressive agents, such as steroids, are used to prevent this disease; however, they have multiple side effects. Therefore, bath psoralen plus ultraviolet-A (PUVA) is an alternative second-line treatment. This study aimed to evaluate the clinical efficacy of bath PUVA for managing chronic graft-versus-host disease. METHODS This retrospective, case-control study included 14 patients with extensive cutaneous chronic graft-versus-host disease, resistant to systemic corticosteroid, treated with bath PUVA. Major and partial responses were defined as clinical improvements of >70% and 50-70%, respectively. We analyzed the graft-versus-host disease clinical presentation and timing after allogeneic stem cell and bone marrow transplantation, bath PUVA doses, background diseases, additional treatments, and adverse effects. RESULTS We observed eight major (three lichenoid and five sclerodermatoid) and six partial (three lichenoid and three sclerodermatoid) responses after a mean of 28 treatment sessions. After 6 to 25 months, four of the eight patients with sclerodermatoid lesions and all those with lichenoid lesions experienced relapse but responded to additional treatment cycles. CONCLUSIONS Bath PUVA is well-tolerated and effective for extensive cutaneous chronic graft-versus-host disease. It allows rapid tapering of adjuvant immunosuppressants; however, most patients require prolonged maintenance phototherapy.
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Affiliation(s)
- Riad Kassem
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
| | - Aviv Barzilai
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
- Dermatopathology Service, Institute of Pathology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
| | - Elon Pras
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
- Institute of Genetics, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
| | - Christina Sizopoulou
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
| | - Felix Pavlotsky
- Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, 69978, Israel
- Phototherapy Unit, Department of Dermatology, Sheba Medical Center, Tel HaShomer, Ramat Gan, 52621, Israel
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Platsidaki E, Tzanetakou V, Kouris A, Stavropoulos PG. Methotrexate: an effective monotherapy for refractory generalized morphea. Clin Cosmet Investig Dermatol 2017; 10:165-169. [PMID: 28507446 PMCID: PMC5428760 DOI: 10.2147/ccid.s134879] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction Morphea is an inflammatory skin disorder characterized by excessive collagen deposition. Although treatment algorithms for morphea subtypes have been suggested, no consistent recommendations are available. This study attempts to evaluate the clinical efficacy of methotrexate (MTX) as monotherapy in refractory generalized morphea. Methods It is a retrospective study, including 20 patients who had already been treated with various topical and systemic therapies with minimal clinical improvement. Patients received orally MTX at a of dosage 15 mg once weekly. Duration of the use, dosage of MTX, and adverse events were recorded. Clinical assessment of skin lesions was performed and documented. Results The mean disease duration was 27 months before the initiation of MTX treatment. After 12 months of therapy, very good response was achieved in 6 patients (30%), good response in 10 patients (50%), and fair response in 2 patients (10%), while 2 patients (10%) had failed treatment. Patients were followed up for a mean time interval of 21 months. No serious adverse event was recorded. Conclusion MTX has been already proved to be an effective and well-tolerated treatment in pediatric patients with morphea. The majority of the group of adult patients showed very good and good improvement when treated with MTX. Although this is an uncontrolled study, MTX monotherapy was considered a safe and effective treatment for the management of this specific clinical subset of morphea in adults.
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Affiliation(s)
- Eftychia Platsidaki
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
| | - Vassiliki Tzanetakou
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
| | - Anargyros Kouris
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
| | - Panagiotis G Stavropoulos
- Department of Dermatology and Venereology, Andreas Syggros Hospital, University of Athens, Athens, Greece
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Abstract
Systemic and localized scleroderma are difficult to manage diseases with no accepted gold standard of therapy to date. Phototherapeutic modalities for scleroderma show promise. A PubMed search of information on phototherapy for scleroderma was conducted. The information was classified into effects on pathogenesis and clinical outcomes. Studies on photopheresis were excluded. There were no randomized, double-blind, placebo-controlled studies, and only three controlled studies. The vast majority of identified studies evaluated ultraviolet A1 (UVA1) phototherapy. More rigorous studies are needed to evaluate phototherapy in the treatment of scleroderma. Based on the limited studies available, 20-50 J/cm2 of UVA1 therapy 3-4 times a week for 30 treatments is recommended.
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Affiliation(s)
- John Hassani
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
| | - Steven R Feldman
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Pavlotsky F, Sakka N, Lozinski A, Barzilai A. Bath psoralen-UVA photochemotherapy for localized scleroderma: experience from a single institute. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2013; 29:247-52. [DOI: 10.1111/phpp.12063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/13/2013] [Indexed: 11/29/2022]
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Abstract
Vitiligo is a disorder with complex causes and is a type of autoimmune disease in which the immune system targets the body's own pigment cells and tissues. Our aim is to present an overall view of the current remedies widely adopted for the treatment of vitiligo. Medical treatments target the immune system, and try to reverse the destruction. The goal is to restore the skin's color by restoring healthy melanocytes to the affected area. Apart from melanocytes, vitiligo autoantigens appear also on other cells. Even though antibodies to pigment cells are not an agent of vitiligo, the most valuable contribution is that anti-melanocyte antibody reactivity can help in identifying relevant antigens. T cells from vitiligo skin are highly reactive towards melanoma cells and serve as an effective source to treat melanoma and stays as a solution for vitiligo. There have been many treatments to cure vitiligo such as use of steroid creams, PUVA (psoralen and ultraviolet A light), narrow band UVB (ultraviolet B), various surgical techniques, vitamin D analogues and pseudocatalase. These treatments are subjected for undesired side effects whereas some herbal and natural treatments act against the immune system with no side effects.
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Affiliation(s)
- M Abu Tahir
- Department of Pharmaceutics, Jamia Hamdard, Hamdard Nagar, New Delhi, India
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Kroft EBM, Creemers MCW, van den Hoogen FHJ, Boezeman JBM, de Jong EMGJ. Effectiveness, side-effects and period of remission after treatment with methotrexate in localized scleroderma and related sclerotic skin diseases: an inception cohort study. Br J Dermatol 2009; 160:1075-82. [PMID: 19210503 DOI: 10.1111/j.1365-2133.2008.09017.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Detailed information is lacking on effectiveness of methotrexate (MTX) in sclerotic skin diseases, side-effects, and duration of remission after discontinuation. OBJECTIVES To determine effectiveness, side-effects and period of remission gained by use of MTX in sclerotic skin diseases. METHODS All patients with a sclerotic skin disease who were treated with MTX (group A) or MTX with corticosteroids (CS) (group B) between 1995 and 2007 were evaluated. Detailed information was collected on dosage and duration of MTX treatment, concomitant immunosuppressive medication and CS treatment, effectiveness, side-effects, duration of the remission period, and time until restart. RESULTS Fifty-eight patients (A, n = 47; B, n = 11) were evaluated. Clinical assessment revealed that 38 patients (81%) treated with MTX and 11 patients (100%) treated with MTX + CS showed improvement of sclerotic skin. After one treatment course 51% of the patients treated with MTX and 73% treated with MTX + CS reached remission status with a median follow-up time of 55 and 58 months. Patients showing relapse still responded to a second and even to a third course of MTX. Patients who showed a relapse had received a lower cumulative dose, due to a shorter period of treatment with MTX in the first course. Serious side-effects were seen in six patients (10%). CONCLUSIONS MTX was an effective treatment for various sclerotic skin diseases with a long period of remission and relatively low toxicity. Patients showing relapse still responded to a second and third course of MTX.
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Affiliation(s)
- E B M Kroft
- Department of Dermatology, Radboud University Medical Centre Nijmegen, St Radboud, PO Box 9101, NL-6500 HB Nijmegen, the Netherlands.
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Kroft EBM, Groeneveld TJ, Seyger MMB, de Jong EMGJ. Efficacy of topical tacrolimus 0.1% in active plaque morphea: randomized, double-blind, emollient-controlled pilot study. Am J Clin Dermatol 2009; 10:181-7. [PMID: 19354332 DOI: 10.2165/00128071-200910030-00004] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Tacrolimus, a calcineurin inhibitor, is an immunomodulating and anti-inflammatory drug that inhibits T-cell activation and production of cytokines. The elevated level of cytokines in morphea causes fibroblast proliferation and subsequent overproduction of collagen. Theoretically, tacrolimus could inhibit the pathophysiologic process of morphea. OBJECTIVE To assess whether tacrolimus 0.1% ointment is an effective treatment for active plaque morphea in a double-blind, placebo (petroleum emollient)-controlled pilot study. METHODS Ten patients with active plaque morphea were included. All patients were treated with tacrolimus 0.1% ointment and with an emollient (petrolatum) on two selected morphea plaques, applied twice daily for 12 weeks. Initial and final assessment included surface area measurements, photography, durometer scores, and clinical feature scores. Adverse reactions were recorded. RESULTS The scleroderma plaques treated with topical tacrolimus 0.1% improved, resulting in a significant reduction in durometer and clinical feature scores. Overall, a significant difference could be found between topical tacrolimus and petrolatum with regard to durometer score (p < 0.005) and the clinical feature score (p = 0.019). CONCLUSION In this first double-blind, placebo-controlled pilot study comparing tacrolimus 0.1% ointment with petrolatum in active plaque morphea, tacrolimus 0.1% ointment was shown to be an effective treatment for this condition.
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Affiliation(s)
- Elisabeth B M Kroft
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Pozo-Román T, González-López A, Velasco-Vaquero ME, Núñez-Cabezón M. Psoralen cream plus ultraviolet A photochemotherapy (PUVA cream): our experience. J Eur Acad Dermatol Venereol 2006; 20:136-42. [PMID: 16441619 DOI: 10.1111/j.1468-3083.2006.01378.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Psoralen ultraviolet A (PUVA) bath photochemotherapy has been proved highly effective in the treatment of various dermatoses without potential side-effects of systemic therapy. Another form of topical PUVA therapy (PUVA cream) without the logistical requirements for bath tubs has recently been developed. OBJECTIVE We sought to develop preparation and treatment standards to PUVA cream and to confirm its clinical efficacy in the treatment of various dermatoses. METHODS In the first phase, the safety of a novel cream containing 0.002% 8-methoxypsoralen (8-MOP) was determined in six healthy volunteers. In a second phase, 40 patients with different dermatoses were treated with a minor concentration (0.001% 8-MOP), following the guidelines for topical PUVA of the British Photodermatology Group. RESULTS Plasma levels of psoralen after the application of the novel cream containing 0.002% 8-MOP, were less than 34 ng/mL, the maximum 8-MOP concentration reported for topical PUVA. With a minor concentration (0.001% 8-MOP), important improvement or healing was found in 53.3% of the cycles, generally with a good response since the first month of treatment. Only mild side-effects were detected in 14 patients. CONCLUSIONS Based on our data, PUVA cream photochemotherapy is well accepted by patients and may be a highly effective treatment even if previous therapy was unsuccessful. In addition, PUVA cream is easier to use than PUVA bath.
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Affiliation(s)
- T Pozo-Román
- Service of Dermatology, Hospital Del Río Hortega, Valladolid, Spain.
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Breuckmann F, Gambichler T, Altmeyer P, Kreuter A. UVA/UVA1 phototherapy and PUVA photochemotherapy in connective tissue diseases and related disorders: a research based review. BMC DERMATOLOGY 2004; 4:11. [PMID: 15380024 PMCID: PMC521488 DOI: 10.1186/1471-5945-4-11] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 09/20/2004] [Indexed: 11/10/2022]
Abstract
BACKGROUND Broad-band UVA, long-wave UVA1 and PUVA treatment have been described as an alternative/adjunct therapeutic option in a number of inflammatory and malignant skin diseases. Nevertheless, controlled studies investigating the efficacy of UVA irradiation in connective tissue diseases and related disorders are rare. METHODS Searching the PubMed database the current article systematically reviews established and innovative therapeutic approaches of broad-band UVA irradiation, UVA1 phototherapy and PUVA photochemotherapy in a variety of different connective tissue disorders. RESULTS Potential pathways include immunomodulation of inflammation, induction of collagenases and initiation of apoptosis. Even though holding the risk of carcinogenesis, photoaging or UV-induced exacerbation, UVA phototherapy seems to exhibit a tolerable risk/benefit ratio at least in systemic sclerosis, localized scleroderma, extragenital lichen sclerosus et atrophicus, sclerodermoid graft-versus-host disease, lupus erythematosus and a number of sclerotic rarities. CONCLUSIONS Based on the data retrieved from the literature, therapeutic UVA exposure seems to be effective in connective tissue diseases and related disorders. However, more controlled investigations are needed in order to establish a clear-cut catalogue of indications.
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Affiliation(s)
- Frank Breuckmann
- Department of Dermatology, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Thilo Gambichler
- Dermatology Out-Patient Clinic, Oldchurch Hospital, Romford RM7 OBE, Greater London, UK
| | - Peter Altmeyer
- Department of Dermatology, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Alexander Kreuter
- Department of Dermatology, Ruhr-University Bochum, 44791 Bochum, Germany
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