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Poli A, Schmitt C, Puy H, Talbi N, Lefebvre T, Gouya L. Erythropoietic protoporphyrias: updates and advances. Trends Mol Med 2024:S1471-4914(24)00128-X. [PMID: 38890030 DOI: 10.1016/j.molmed.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024]
Abstract
Protoporphyrias are caused by pathogenic variants in genes encoding enzymes involved in heme biosynthesis. They induce the accumulation of a hydrophobic phototoxic compound, protoporphyrin (PPIX), in red blood cells (RBCs). PPIX is responsible for painful cutaneous photosensitivity, which severely impairs quality of life. Hepatic elimination of PPIX increases the risk of cholestatic liver disease, requiring lifelong monitoring. Treatment options are scarce and mainly limited to supportive care such as protection from visible light. Here, we review the pathophysiology of protoporphyrias, their diagnosis, and current recommendations for medical care. We discuss new therapeutic strategies, some of which are currently undergoing clinical trials and are likely to radically alter the severity of the disease in the years to come.
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Affiliation(s)
- Antoine Poli
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France.
| | - Caroline Schmitt
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France
| | - Hervé Puy
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France
| | - Neila Talbi
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
| | - Thibaud Lefebvre
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
| | - Laurent Gouya
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France
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Heerfordt IM, Lerche CM, Philipsen PA, Wulf HC. Effects of iron supplements in individuals with erythropoietic protoporphyria. Photodiagnosis Photodyn Ther 2024; 47:104211. [PMID: 38734198 DOI: 10.1016/j.pdpdt.2024.104211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Protoporphyrin IX (PPIX) is the final precursor of heme, forming heme when iron is inserted. Individuals with erythropoietic protoporphyrias (EPP) have accumulation of PPIX, causing photosensitivity and increased liver disease risk. Many also have iron deficiency and anemia. We investigated outcomes of oral iron supplements in individuals with EPP. METHODS A systematic review identified literature on oral iron supplements in EPP patients. Subsequently, we administered iron supplements to EPP patients with iron deficiency. The primary outcome was impact on PPIX level. Secondary outcomes were adverse events and relative differences in hemoglobin and iron parameters. RESULTS The systematic review found 13 case reports and one uncontrolled clinical trial with uncertain results. From our department 10 patients with EPP and iron deficiency took daily dosages of 330 mg of ferrous fumarate for two months. Five of our patients had anemia at baseline. After 2 months of supplementation seven patients had increased PPIX level compared to baseline, two had decrease, one remained unchanged. The administration of iron led to a rise in ferritin, and in four of the anemic patients also to an improvement in blood hemoglobin. A small transiently elevation in plasma alanine transaminase concentration was observed during supplementation. CONCLUSIONS Overall, iron supplementation in EPP patients replenished iron stores and elevated erythrocyte PPIX and plasma alanine transaminase. For anemic patients, there was some degree of normalization of the hemoglobin level. If iron therapy is needed for EPP patients, monitoring of photosensitivity, PPIX, hemoglobin, and plasma liver enzymes is advisable.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark; Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark.
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark; Department of Pharmacy, University of Copenhagen, Denmark
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
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3
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Dittmann MT, Lakatos G, Wainwright JF, Mokrosinski J, Cross E, Farooqi IS, Wallis NJ, Halsey LG, Wilson R, O’Rahilly S, Yeo GS, Raffan E. Low resting metabolic rate and increased hunger due to β-MSH and β-endorphin deletion in a canine model. SCIENCE ADVANCES 2024; 10:eadj3823. [PMID: 38446876 PMCID: PMC10917344 DOI: 10.1126/sciadv.adj3823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/31/2024] [Indexed: 03/08/2024]
Abstract
Mutations that perturb leptin-melanocortin signaling are known to cause hyperphagia and obesity, but energy expenditure has not been well studied outside rodents. We report on a common canine mutation in pro-opiomelanocortin (POMC), which prevents production of β-melanocyte-stimulating hormone (β-MSH) and β-endorphin but not α-MSH; humans, similar to dogs, produce α-MSH and β-MSH from the POMC propeptide, but rodents produce only α-MSH. We show that energy expenditure is markedly lower in affected dogs, which also have increased motivational salience in response to a food cue, indicating increased wanting or hunger. There was no difference in satiety at a modified ad libitum meal or in their hedonic response to food, nor disruption of adrenocorticotropic hormone (ACTH) or thyroid axes. In vitro, we show that β-MSH signals comparably to α-MSH at melanocortin receptors. These data implicate β-MSH and β-endorphin as important in determining hunger and moderating energy expenditure and suggest that this role is independent of the presence of α-MSH.
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Affiliation(s)
- Marie T. Dittmann
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Gabriella Lakatos
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Jodie F. Wainwright
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Jacek Mokrosinski
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Eloise Cross
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - I. Sadaf Farooqi
- University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Wellcome-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, UK
| | - Natalie J. Wallis
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Lewis G. Halsey
- School of Life and Health Sciences, University of Roehampton, London, UK
| | - Rory Wilson
- Department of Biosciences, Swansea University, Swansea, UK
| | - Stephen O’Rahilly
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Giles S.H. Yeo
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Eleanor Raffan
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
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Christian L, Manjrekar P, Henkels KM, Rapp CM, Annamraju R, Lohade RP, Singh S, Carpenter MA, Khan S, Kemp MG, Chen Y, Sahu RP, Travers JB. Evidence for the involvement of keratinocyte-derived microvesicle particles in the photosensitivity associated with xeroderma pigmentosum type A deficiency. Photochem Photobiol 2024. [PMID: 38287748 DOI: 10.1111/php.13915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 01/31/2024]
Abstract
Photosensitivity can be due to numerous causes. The photosensitivity associated with deficiency of xeroderma pigmentosum type A (XPA) has been previously shown to be associated with excess levels of the lipid mediator platelet-activating factor (PAF) generated by the keratinocyte. As PAF has been reported to trigger the production of subcellular microvesicle particles (MVP) due to the enzyme acid sphingomyelinase (aSMase), the goal of these studies was to discern if PAF and aSMase could serve as therapeutic targets for the XPA deficiency photosensitivity. HaCaT keratinocytes lacking XPA generated greater levels of MVP in comparison to control cells. Mice deficient in XPA also generated enhanced MVP levels in skin and in plasma in response to UV radiation. Use of a genetic strategy with mice deficient in both XPA and PAF receptors revealed that these mice generated less MVP release as well as decreased skin erythema and cytokine release compared to XPA knockout mice alone. Finally, the aSMase inhibitor imipramine blocked UV-induced MVP release in HaCaT keratinocytes, as well as XPA knockout mice. These studies support the concept that the photosensitivity associated with XPA involves PAF- and aSMase-mediated MVP release and provides a potential pharmacologic target in treating this form of photosensitivity.
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Affiliation(s)
- Lea Christian
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Pranali Manjrekar
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Karen M Henkels
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Christine M Rapp
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Risha Annamraju
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Rushabh P Lohade
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Shikshita Singh
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | | | - Saman Khan
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Michael G Kemp
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
- The Dayton V.A. Medical Center, Dayton, Ohio, USA
| | - Yanfang Chen
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Ravi P Sahu
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
| | - Jeffrey B Travers
- Department of Pharmacology & Toxicology, Wright State University, Dayton, Ohio, USA
- The Dayton V.A. Medical Center, Dayton, Ohio, USA
- Department of Dermatology, Wright State University, Dayton, Ohio, USA
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Hussain Z, Qi Q, Zhu J, Anderson KE, Ma X. Protoporphyrin IX-induced phototoxicity: Mechanisms and therapeutics. Pharmacol Ther 2023; 248:108487. [PMID: 37392940 PMCID: PMC10529234 DOI: 10.1016/j.pharmthera.2023.108487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/03/2023]
Abstract
Protoporphyrin IX (PPIX) is an intermediate in the heme biosynthesis pathway. Abnormal accumulation of PPIX due to certain pathological conditions such as erythropoietic protoporphyria and X-linked protoporphyria causes painful phototoxic reactions of the skin, which can significantly impact daily life. Endothelial cells in the skin have been proposed as the primary target for PPIX-induced phototoxicity through light-triggered generation of reactive oxygen species. Current approaches for the management of PPIX-induced phototoxicity include opaque clothing, sunscreens, phototherapy, blood therapy, antioxidants, bone marrow transplantation, and drugs that increase skin pigmentation. In this review, we discuss the present understanding of PPIX-induced phototoxicity including PPIX production and disposition, conditions that lead to PPIX accumulation, symptoms and individual differences, mechanisms, and therapeutics.
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Affiliation(s)
- Zahir Hussain
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Qian Qi
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Junjie Zhu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Xiaochao Ma
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Heerfordt IM, Philipsen PA, Lerche CM, Wulf HC. Phototesting in erythropoietic protoporphyria trials: A systematic review. Exp Dermatol 2023. [PMID: 37052136 DOI: 10.1111/exd.14809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Abstract
Severe skin pain when exposed to long wave ultraviolet radiation or visible light is the main symptom of erythropoietic protoporphyria (EPP). Treatment options for EPP are inadequate and new treatments are needed but hampered by the lack of valid efficacy outcomes. Phototesting with well-defined illumination of the skin can be performed reliably. We aimed to provide an overview of phototest procedures used to evaluate EPP treatments. Systematic searches of Embase, MEDLINE and the Cochrane Library were performed. Searches identified 11 studies using photosensitivity as efficacy outcome. The studies used eight different phototest protocols. Illuminations were performed with a filtered high-pressure mercury arc, or a xenon arc lamp equipped with monochromator or filters. Some used broadband, others narrowband illumination. In all protocols phototests were performed on the hands or the back. Endpoints were minimal dose required to induce either first symptom of discomfort, erythema, urticaria or intolerable pain. Other endpoints were change in erythema intensity or diameter of any type of flare after exposure compared to before. In conclusion, protocols displayed extensive variability in illumination set-up and evaluation of phototest reactions. Implementation of a standardized phototest method will allow more consistent and reliable outcome evaluation in future therapeutic research of protoporphyric photosensitivity.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Barman-Aksözen J, Minder AE, Granata F, Pettersson M, Dechant C, Aksözen MH, Falchetto R. Quality-Adjusted Life Years in Erythropoietic Protoporphyria and Other Rare Diseases: A Patient-Initiated EQ-5D Feasibility Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5296. [PMID: 37047912 PMCID: PMC10094018 DOI: 10.3390/ijerph20075296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 06/19/2023]
Abstract
Erythropoietic protoporphyria (EPP) is an ultra-rare inborn error of metabolism characterised by painful phototoxic burn injuries after short exposure times to visible light. Patients with EPP are highly adapted to their condition which makes the quantification of their health-related quality of life (QoL) challenging. In the presented patient-initiated feasibility study, we describe a new approach to assess treatment benefits in EPP by measuring QoL with the generic EQ-5D instrument in five patients under long-term (≥two years) treatment with afamelanotide, the first approved therapy for EPP. For the study, we selected patients with EPP who in addition were affected by an involuntary treatment interruption (caused by a temporary reimbursement suspension) because we hypothesized that individuals who had previously unlearned their adaptation are better able to assess their life without treatment than treatment-naïve patients. QoL under treatment was comparable to the age-matched population norm, and retrospective results for a treatment interruption and phototoxic reaction time point were comparable to the QoL of patients with chronic neuropathic pain and acute burn injuries, respectively. The results were accepted by the National Institute for Health and Care Excellence in England for their evaluation of the cost-effectiveness of afamelanotide, i.e., the calculation of quality-adjusted life years.
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Affiliation(s)
- Jasmin Barman-Aksözen
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
- Institute of Laboratory Medicine, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Anna-Elisabeth Minder
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
- Division for Endocrinology, Diabetology and Porphyria, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Francesca Granata
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, S.C Medicine and Metabolic Disorders, 20122 Milano, Italy
| | - Mårten Pettersson
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
| | - Cornelia Dechant
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
| | | | - Rocco Falchetto
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
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Heerfordt IM, Philipsen PA, Lerche CM, Wulf HC. Protection against visible light by dihydroxyacetone in erythropoietic protoporphyria. Photodiagnosis Photodyn Ther 2023; 41:103302. [PMID: 36690194 DOI: 10.1016/j.pdpdt.2023.103302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with erythropoietic protoporphyria (EPP) are hypersensitive to long wave ultraviolet (UVA) radiation and visible light and they experience severe skin pain by light exposure. The patients have very limited treatment options. Sunless skin tanning with dihydroxyacetone (DHA) is now being investigated as a possible treatment modality of skin photosensitivity in EPP. METHODS We simulated the theoretical light protection factor provided by DHA application. In addition, we present 19 cases with EPP who were treated at our department with DHA weekly during spring and summer from 2018 to 2021 inclusive. RESULTS The protection factor against UVA and visible light was estimated to approximately two. Out of the 19 patients with EPP who were treated with DHA in 2018, 11 patients experienced a sustained good effect and continued to use the treatment on a weekly basis in the spring and summer of 2019, 2020, and 2021. CONCLUSION AND PERSPECTIVES Both the theoretical estimates and the uncontrolled study suggest that sunless tanning with DHA reduces photosensitivity in patients with EPP. Our hypothesis is that skin treated with DHA can tolerate twice the daylight dose compared to untreated skin before onset of skin symptoms. To validate this conclusion, we plan a randomized clinical trial to determine the effect of DHA application to reduce photosensitivity in patients with EPP under controlled clinical conditions. The study protocol for this trial is presented in the paper.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark.
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark; Department of Pharmacy, University of Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
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