Prospects for UV-A1 therapy as a treatment modality in cutaneous and systemic LE

Lupus erythematosus: systemic and cutaneous manifestations

Skin and joint involvements are the most commonly occurring manifestations of systemic lupus erythematosus. There are 3 forms of cutaneous lupus: chronic cutaneous (discoid) lupus, subacute cutaneous lupus, and acute cutaneous lupus. Joint manifestations are usually not associated with warmth of the joints and may be only associated with pain and swelling. Painful or swollen joints respond rapidly to small or moderate doses of corticosteroids, whereas cutaneous manifestations usually respond to antimalarial drugs. Anti-Ro is associated closely with a photosensitive rash and with subacute lupus.

UV hardening therapy: a novel intervention in patients with photosensitive cutaneous lupus erythematosus

BACKGROUND

Patients with cutaneous lupus erythematosus (LE) and a history of disease- related photoaggravation, confirmed by phototesting, may not respond to photoprotection and/or medical intervention. Ultraviolet B-hardening therapy may improve tolerance for environmental ultraviolet radiation (UVR) in photosensitive disorders.

OBJECTIVE

We studied the effect of UVB hardening on the cutaneous manifestations of patients with LE and their tolerance for UVR.

PATIENTS AND METHODS

A retrospective study of continuous, home-based, UVB-hardening therapy in 44 patients with cutaneous LE (systemic LE: 9 patients; chronic LE: 21 patients; subacute cutaneous LE: 10 patients; cutaneous LE not specified: 4 patients) who had confirmed photosensitivity. Exposure to the UVB source was performed year-round, 3 times weekly, with increasing doses to a maximum of 10 minutes per session. Tolerance for environmental UVR was established through questionnaires, phototesting, and assessment of disease activity by physician and patient.

RESULTS

Of 44 patients, 35 were able to gradually increase their monthly UVB doses. Nine patients dropped out because of insufficient efficacy or skin irritation, or were unable to adhere to the hardening regimen. Of the 35 patients who succeeded in hardening their skin with UVB, 28 patients reported an improved tolerance for environmental UVR. This outcome was confirmed by repeat phototesting in a subgroup. In only 5 patients, an improvement of cutaneous LE symptoms was noted by either physician or patient. No serious adverse events were encountered.

LIMITATIONS

This was a retrospective study and no control group was used.

CONCLUSION

This is the first report that describes UVB hardening as a potential therapy in patients with cutaneous LE and confirmed photosensitivity. This intervention may lead to improved tolerance for environmental UVR and, in a minority of patients, even to decreased cutaneous activity of LE.

Ultraviolet therapy in lupus

This review examines the use of ultraviolet (UV) therapy in lupus erythematosus (LE), a disorder usually associated with abnormally increased photosensitivity. In addition to the abnormal cutaneous response to ultraviolet radiation (UVR) exposure, photo-aggravation of systemic disease activity in systemic LE (SLE) may also occur. However, courses of UVR exposure may also be used in the treatment or prophylaxis of various photodermatoses, and LE now appears to be included in that group. Thus, several studies have reported apparent benefits of phototherapy in both cutaneous and systemic LE, although the underlying mechanisms remain obscure and final confirmation of such efficacy is still awaited in continuing studies.

UVA-1 cold light treatment of SLE: a double blind, placebo controlled crossover trial

OBJECTIVE

Treatment of patients with systemic lupus erythematosus (SLE) often implies strong drugs with possibly serious side effects. Thus there is a need for new immunosuppressive treatments. Long wave ultraviolet A (UVA-1) cold light therapy is an anti-inflammatory, immunomodulatory treatment with a possible systemic effect and few side effects. In the current study low dose UVA-1 cold light treatment was tested to determine whether it reduces disease activity in SLE.

METHODS

Eleven patients with SLE were treated with UVA-1 cold light treatment and a placebo light treatment in a double blind, placebo controlled, crossover study. In two consecutive 12 week periods the patients were treated in the first three weeks with UVA-1 and placebo treatment or vice versa. The primary variables were the SLE Disease Activity Index (SLEDAI) and SLE Activity Measure (SLAM).

RESULTS

The mean SLAM and SLEDAI showed a significant decrease of 30.4% (p=0.0005) and 37.9% (p=0.016) respectively after three weeks of UVA-1 and a non-significant decline of 9.3% (p=0.43) and 12.2% (p=0.54) respectively after three weeks of placebo treatment. In this small trial the difference in reduction of the disease activity indices during UVA-1 compared with during placebo treatment failed to reach the conventional border of significance (p=0.07). The total score of quality of life measure RAND-36 did not improve significantly, but the subscore for vitality did improve.

CONCLUSION

Low dose UVA-1 cold light treatment was strongly suggestive of lowering disease activity in this double blind placebo controlled study, and no side effects occurred.

Photosensitivity in lupus

A wide variety of skin conditions may present in patients with lupus erythematosus (LE). These can be broadly divided into three main groups: cutaneous forms of LE ('LE-specific skin disease'), non-specific cutaneous manifestations of SLE ('LE non-specific skin disease') and cutaneous complications of drug treatments for LE. This review examines clinical photosensitivity in LE, a trait most commonly associated with cutaneous forms of LE but which may also manifest in SLE. All humans are photosensitive, developing reddening of the skin if exposed to sufficient ultraviolet radiation (UVR). Therefore we define photosensitivity in clinical practice as an abnormal cutaneous response to UVR. Abnormal photosensitivity in LE may manifest in a number of different forms. The lesions of LE-specific skin disease may be induced or exacerbated by UVR. Patients with LE who are prescribed photosensitizing medications such as thiazide diuretics, neuroleptics and tetracyclines may also develop phototoxic reactions which usually present as easy sunburn. Photosensitivity may also, rarely, manifest as fragile skin and blistering in patients with both LE and porphyria cutanea tarda. Several other photosensitive disorders have been reported in association with LE, including solar urticaria and erythropoetic protoporphyria (EPP), but these appear to be chance associations. Assessment of patients with LE and photosensitivity requires a careful history and examination. Phototesting and photoprovocation tests may be used to demonstrate photosensitivity in some cases, but these are rarely required for diagnosis. Photosensitive patients should be advised about sun avoidance, photoprotection and sunscreen use as a first line treatment.