Japanese guidelines for the management and treatment of generalized pustular psoriasis: The new pathogenesis and treatment of GPP

Generalized pustular psoriasis (GPP) is a rare disease characterized by recurrent fever and systemic flushing accompanied by extensive sterile pustules. The committee of the guidelines was founded as a collaborative project between the Japanese Dermatological Association and the Study Group for Rare Intractable Skin Diseases under the Ministry of Health, Labour, and Welfare Research Project on Overcoming Intractable Diseases. The aim of the guidelines was to provide current information to aid in the treatment of patients with GPP in Japan. Its contents include the diagnostic and severity classification criteria for GPP, its pathogenesis, and recommendations for the treatment of GPP. Since there are few clinical trial data with high levels of evidence for this rare disease, recommendations by the committee are described in the present guidelines.

The Vitiligo Working Group recommendations for narrowband ultraviolet B light phototherapy treatment of vitiligo

BACKGROUND

Treatment of vitiligo with narrowband ultraviolet B light (NBUVB) is an important component of the current standard of care. However, there are no consistent guidelines regarding the dosing and administration of NBUVB in vitiligo, reflected by varied treatment practices around the world.

OBJECTIVE

To create phototherapy recommendations to facilitate clinical management and identify areas requiring future research.

METHODS

The Vitiligo Working Group (VWG) Phototherapy Committee addressed 19 questions regarding the administration of phototherapy over 3 conference calls. Members of the Photomedicine Society and a group of phototherapy experts were surveyed regarding their phototherapy practices.

RESULTS

Based on comparison and analysis of survey results, expert opinion, and discussion held during conference calls, expert recommendations for the administration of NBUVB phototherapy in vitiligo were created.

LIMITATIONS

There were several areas that required further research before final recommendations could be made. In addition, no standardized methodology was used during literature review and to assess the strength of evidence during the development of these recommendations.

CONCLUSION

This set of expert recommendations by the VWG is based on the prescribing practices of phototherapy experts from around the world to create a unified, broadly applicable set of recommendations on the use of NBUVB in vitiligo.

Comparison of Phototherapy Guidelines for Psoriasis: A Critical Appraisal and Comprehensive Review

Psoriasis is a common, chronic immune-mediated inflammatory skin disorder that significantly impacts quality of life and has potential systemic complications. The majority of psoriatic patients have mild to moderate disease and are adequately controlled with topical medications. However, approximately 20% of patients have moderate-to-severe disease. Phototherapy has remained a mainstay option for patients with moderate-to-severe psoriasis resistant to topical treatments due to its efficacy, cost-effectiveness, and relative lack of side effects, in particular a lack of systemic immunosuppression seen with traditional and biologic systemic therapies. There are several well-established guidelines for phototherapy treatment of psoriasis proposed in the United States by the American Academy of Dermatology (AAD), in Europe by the European S3, and in the United Kingdom by the National Institute for Health and Care Excellence (NICE). The guidelines set by these groups are largely based on current evidence or expert panel consensus where evidence is lacking. This article reviews and compares the current recommendations of these guidelines for psoriasis phototherapy in regards to the initial clinical encounter, dosage, adverse reactions, and special considerations.<br /><br /> <em>J Drugs Dermatol</em>. 2016;15(8):995-1000.

UV emissions from artificial tanning devices and their compliance with the European technical standard

Use of ultraviolet radiation-emitting tanning devices has been classified as "carcinogenic to humans" (group 1) by the International Agency for Research on Cancer. Following this classification, the knowledge of typical ultraviolet emission levels from tanning devices can be of interest for evaluating their impact on health. In this work, the results of an extensive measurement campaign on artificial tanning appliances are presented. Ultraviolet emissions from 94 tanning appliances produced by 15 different manufacturers were characterized by onsite spectroradiometric measurements. The measured radiometric quantities were compared with reference values fixed in the European technical standard EN 60335-2-27 "Household and similar electrical appliances-Safety. Part 2: Particular requirements for appliances for skin exposure to ultraviolet and infrared radiation." Measurement results indicate that 88% of the examined appliances had ultraviolet emissions not compliant with the technical standard. Among the considered appliances, tanning devices equipped with low pressure lamps showed higher ultraviolet levels of effective irradiance and less compliance with standard requirements. In particular, UV emissions from 100% of low pressure appliances and from 78% of high pressure appliances exceeded the irradiance limit of 0.3 Wm set by the European technical standard.

Tanning lamps ultraviolet emissions and compliance with technical standards

In this work the compliance of tanning lamps with technical standards EN 60335-2-27 'Household and similar electrical appliances-Safety. Part 2: Particular requirements for appliances for skin exposure to ultraviolet and infrared radiation' was analysed. Results of this analysis showed that none of the examined technical documentation produced by the lamps manufacturers is fully compliant with the standard technique. Furthermore data reported in the same manuals, such as effective radiant exposure or irradiance, would indicate that these sources may be the cause of undue exposure to ultraviolet (UV) radiation. For this reason a measurement campaign on UV lamps used in tanning salons was organised. The first results of these measurements seem to confirm the doubts raised from the analysis of the lamp manuals: the use of a tanning lamp can lead to UV radiation exposure levels higher than reference maximum values recommended by EN 60335-2-27.

Implementierung der S3-Leitlinien zur systemischen und UV-Therapie der mittelschweren bis schweren Psoriasis vulgaris durch einen Therapiealgorithmus

The recently published German S3- guidelines for the treatment of psoriasis vulgaris offer an extensive evidence-based documentation and evaluation of currently available treatment modalities. In order to incorporate this detailed information into the actual treatment decisions in individual patients, we have transformed the recommendations regarding phototherapy and systemic therapies into an algorithm. This algorithm should allow a stepwise treatment approach in adult patients with moderate to severe psoriasis, in whom topical therapy is not sufficient. It can also facilitate documentation of treatment. In our hands the treatment algorithm proved to be feasible and reliable in a large number of patients.

Ultraviolet action spectrum for cell killing in a human lens epithelial cell line

There are many sources of ultraviolet (UV) radiation in the workplace. Action spectrum data are necessary for establishing methods to evaluate UV hazards. We determined a UV action spectrum for cell killing in the human lens epithelial cell line SRA 01/04 by measuring the viability of cells exposed to UV at 8 different wavelengths ranging from 259.5 to 300.5 nm in a carefully designed and controlled experiment. The action spectrum based on LD50 is nearly flat or falls slightly with wavelength in the short-wavelength region and then rises increasingly steeply at longer wavelengths. UV at 267.5 nm is most effective in cell killing, with an LD50 of 8.86 Jm(-2). The action spectrum for killing lens epithelial cells in humans (in vivo action spectrum) derived from the present results falls monotonically with wavelength in the range studied, suggesting that UV at wavelengths longer than 300.5 nm may also be highly effective in killing lens epithelial cells in humans and, therefore, in causing cataract. Further studies should be conducted with UV at longer wavelengths.

Photoadaptation: A Path Toward Rational Phototherapy Protocols

Photoadaptation is defined as the diminished future response to equivalent doses of irradiation. It is most often estimated in vivo by looking at changes in the minimal erythema dose with subsequent doses of UV radiation. Although photoadaptation's mechanism of action is poorly understood, Palmer et al. help clarify the clinical significance of photoadaptation for the dosimetry of UV-based phototherapy.

Environmental risk analysis of ultraviolet phototherapy centres in Ireland

BACKGROUND

Ultraviolet (UV) radiation is commonly used in the treatment of dermatological conditions such as psoriasis. It is known that high levels of exposure to UV radiation (UVR) will increase the risk of adverse biological effects. Exposure limit values for UVR have been developed by the International Commission on Non-Ionising Radiation Protection (ICNIRP) and occupational exposure to phototherapy staff should be kept within these limits. The use of environmental controls such as warning signs, good ventilation and UV-opaque curtains will significantly reduce the risks to staff, patients and members of the public.

AIMS

The aim of the study is to identify hazards in phototherapy centres and present recommendations for reducing risks.

METHODS

An environmental risk assessment has been carried out at eleven phototherapy centres in the Republic of Ireland. The study assessed a number of areas such as patient safety, staff safety, room design and UV leakage measurements.

RESULTS

The majority of clinics are well designed and there is consistent use of protective equipment.

CONCLUSIONS

The results show that on the whole there is a satisfactory level of risk management in phototherapy centres. Recommendations on maintaining good safety standards are presented.

Photoadaptation during Narrowband Ultraviolet-B Therapy Is Independent of Skin Type: A Study of 352 Patients

Understanding how photoadaptation differs between individuals is important when considering susceptibility to the beneficial and harmful effects of sunlight exposure and when determining optimal phototherapy regimens. Most narrowband UVB (NB-UVB) regimens start with 70% of the minimal erythema dose (MED) with 20% increments at each treatment thereafter. We retrospectively studied 352 skin types I-IV psoriatic patients having twice weekly treatment with this regimen. Patients with high skin types tended to have high MEDs (P<0.001). By session 20 the proportion of patients who had developed erythema was approximately 60% regardless of MED. Among patients who developed erythema, the number of treatments before erythema occurred did not differ between skin types (P=0.33). We conclude that patients with high skin types photoadapt approximately equally per physical unit of UVR in comparison to those with low skin types, but they have greater photoadaptation in absolute terms because they are able to tolerate a higher initial dose of radiation. Differences in skin type or MED are not associated with clinically important differences in tendency to erythema during a standard 70/20% NB-UVB twice-weekly regimen. This regimen is suitable for all skin types I-IV patients regardless of skin type or MED.

Instrument for scanning the angular variation of irradiance in ultraviolet phototherapy cabinets

An instrument is described that measures irradiance and the angular distribution of the intensity of ultraviolet radiation sources inside phototherapy cabinets. Failed lamps and lamps with higher or lower outputs are readily identified. The measurements are controlled from outside the cabinet, thus reducing the risk to staff from exposure to ultraviolet radiation.

Long-term results in the treatment of vitiligo with oral khellin plus UVA

This study was performed to assess the effectiveness and short-term and long-term safety of oral khellin plus UVA (KUVA) in patients with vitiligo. Twenty-eight patients (13 males and 15 females; mean age, 34 years; [age range, 15-51 years]) most with extensive generalized vitiligo of more than 6 months duration had received KUVA at sometime during a 14-year period. The response to treatment (i.e. repigmentation of depigmented areas) was rated retrospectively comparing photographs taken before and after therapy and correlation analysis revealed that it was statistically significantly linked to the number of KUVA treatments (r = 0.833, P = 0.001) and to total cumulative UVA dose (r = 0.840, P = 0.001). Of 17 patients who had continued therapy for longer than 3 months, 7 (41%) had a good response (i.e., more than 70% repigmentation of lesional skin) after a mean of 194 treatments (range, 69-386 treatments) and a mean cumulative UVA dose of 2,036 J/cm2 (range, 690-4,411 J/cm2), whereas lower response grades were observed in the patients with lower treatment numbers. The most common short-term side effect was mild nausea, occurring in 8 of 28 patients (29%), and mainly in the first week(s) of treatment. Follow-up assessment at a mean of 40 months (range, 4-110 months) after the end of KUVA therapy available in 23 of 28 patients revealed no skin cancers or actinic skin damage in any patient. These data indicate that KUVA seems to be safe as well as effective for vitiligo, provided treatment is administered long enough.

Phototherapy for atopic dermatitis

The beneficial effects of ultraviolet (UV) radiation on atopic dermatitis has been appreciated for many years. While broadband UVB and psoralen UVA have been the mainstay of phototherapy for some time, the past 5 years have seen the introduction of phototherapeutic modalities, including UVA-1 and 311nm UVB. The best modality and mode of usage is dependent on the type of atopic dermatitis, severity and body site. T lymphocytes play an important role in disease pathogenesis and UV radiation has profound effects on skin and systemic immune responses.

Immunomodulation in transplantation with photopheresis

Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoactivatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregulatory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.

The practice of ultraviolet phototherapy in the United Kingdom

A survey, using a postal questionnaire, was carried out to examine the current practice of UVB phototherapy in dermatology centres in the U.K. The questionnaire was sent to 115 dermatology departments, and sought information regarding the type and age of each machine used for ultraviolet B (UVB) phototherapy, methods of prescribing, recording and terminating patient exposure, and the skin conditions treated. Completed questionnaires were received from 87 of the 115 centres, giving a response rate of 76%. The survey showed that an appreciable number of U.K. phototherapy centres are using equipment which is both old, and suboptimal in producing a therapeutic response. There appeared to be a wide variation in the approach to phototherapy, both in terms of prescribing initial and incremental exposure, and in terminating treatment. The findings suggest that effectiveness and efficiency might be improved, and the risk/benefit ratio of phototherapy further reduced, by some rationalization of treatment protocols.

Psoriasis: therapeutic aspects

Some of the more common features of psoriasis are reviewed here as an introduction to therapeutic modalities that can be employed in the management of this disorder in the New Zealand situation. An approximate indication of costs for the various therapies is included. This article is sponsored by the therapeutics section of the Department of Health, however, the views of the contributors do not necessarily reflect departmental policies.

The UVB content of 'UVA fluorescent lamps' and its erythemal effectiveness in human skin

The UVB emission from ten different types of 'UVA fluorescent lamp' has been measured by spectroradiometry. The mean ratio of UVB emission to UVA emission was found to be 0.94 +/- 0.35 (1 SD)%. By weighting the spectral irradiance of each lamp by the DIN standard erythemal curve, the mean erythemally effective UVB emission (normalised to 297 nm), expressed as a percentage of the UVA emission, was 0.076 +/- 0.049 (1 SD)%.