Shower PUVA: A Novel Variant of Photochemotherapy

Shower PUVA is a new variant of photochemotherapy suitable for therapy of various skin disorders. Psoralen, e.g. trioxsalen-containing water recirculates in a closed shower system and wets the skin continuously. After showering, whole-body UVA irradiation (320-400 nm) is performed. In order to prove the equal distribution of photosensitivity in vivo minimal phototoxic dose (MPD) was determined in different skin areas of healthy individuals. Additionally, we investigated the accumulation of trioxsalen in psoriasis lesions under the conditions described by quantifying psoralen in scales collected after showering. In a randomized study 20 healthy volunteers (skin type I-III) took showers for 5 and 10 min in trioxsalen (0.27 mg/l)-containing water at 37 degrees C. Immediately afterwards, MPD was tested on the inside of the upper arms and on the buttocks by using a polychromator light source (315-400 nm). The applied UVA doses were 0.06-0.75 J/cm(2) with steps of 0.125 J/cm(2). MPD was evaluated after 72 h. Equal distribution of photosensitivity was defined as equal MPD on the insides of the upper arm and the buttocks (+/-0.125 J/cm(2)). Skin scales of 21 patients with psoriasis were collected by scratching after showering with trioxsalen-containing water (0.27 mg/l) for 5 min. For quantification of trioxsalen in the scales HPLC was performed. An equal distribution of photosensitivity was achieved in 70% (14/20) cases after 10-min showering in trioxsalen-containing water. Showering for 5 min only revealed a 30% (6/20) rate of equal distributed photosensitivity. After 10-min shower time MPD was 0.325 J/cm(2) (median; range: 0.06-0.625 J/cm(2)). The average amount of trioxsalen found in the scales was 2.03 ng/mg scales (range: 0.38-7.2 ng/mg). For shower PUVA using trioxsalen, 10 min shower time is recommended to achieve sufficient distribution of photosensitivity on the skin. Clinical efficacy of shower PUVA can be explained by skin accumulation of trioxsalen which enters from the aqueous phase into the upper skin layers in detectable amounts. This is the first report demonstrating the efficacy of shower PUVA which in short shower time allows an uptake of psoralen by the skin.

An intraindividual comparative study of psoralen-UVA erythema induced by bath 8-methoxypsoralen and 4, 5', 8-trimethylpsoralen

BACKGROUND

Limited work has been conducted on the characteristics of topical trimethylpsoralen (TMP) psoralen-UVA (PUVA) erythema.

OBJECTIVE

We sought to determine the time-course and dose-response characteristics of erythema induced by topical TMP, and to compare these parameters with those for topical 8-methoxypsoralen (MOP) within patients.

METHODS

After photosensitization of one forearm with topical TMP, test sites were exposed to a UVA dose series. The procedure was repeated on the other forearm using 8-MOP solution. Erythema was assessed visually and with a reflectance instrument every 24 hours for 7 days.

RESULTS

TMP PUVA erythema followed a similar time course to 8-MOP PUVA erythema. The majority of patients were at maximal erythema at or beyond 96 hours. TMP PUVA had a significantly steeper dose-response curve at 48, 72, and 96 hours compared with 8-MOP PUVA.

CONCLUSION

On the basis of these data, the optimal time to read the TMP minimal phototoxic dose is 96 hours. In view of the steeper dose-response curve for TMP PUVA, a lower UVA incremental regimen should be considered compared with that for 8-MOP PUVA.

Kinetics of phototoxicity in trioxysalen bath psoralen plus ultraviolet A photochemotherapy

A trioxysalen bath is a safe alternative to systemic 8-methoxypsoralen in long-term psoralen plus ultraviolet A (PUVA) treatment. The kinetics of its main side-effect, the strong phototoxicity, has not been thoroughly studied. This study determined the degree and persistence of phototoxicity after a single 10 min bath at a trioxysalen concentration of 0.33 mg/l. The buttock skin of 16 healthy volunteers was irradiated with UVA 10 min, and 1, 3, 9 and 24h after the bath. The minimal phototoxic dose (MPD) was assessed 48, 72 and 96h after the bath. In general, the 96 h reading showed the lowest values of MPD; for example, a median of 0.14 J/cm2 (95% confidence interval 0.10-0.14 J/cm2) at sites irradiated 10 min after the bath. The values increased progressively with later irradiation, and the maximum dose applied, 18.32 J/cm2, failed to produce any redness when irradiation was given 24 h after the bath. Substantial phototoxicity persists up to at least 9h after the trioxysalen bath, making it wise for patients to avoid sunshine for at least the rest of the day.

Concentration-dependent phototoxicity in trimethylpsoralen bath psoralen ultraviolet A

BACKGROUND

Long-term use of topical trimethylpsoralen (TMP) psoralen bath plus ultraviolet A (bath PUVA) is considered safe with regard to the risk of skin cancer. However, the potential for severe phototoxicity limits its use.

OBJECTIVES

To study the effect of dilution of the TMP bath on the minimal phototoxic dose (MPD).

METHODS

Fifteen volunteers participated in the study. The MPD tests were performed for three TMP concentrations: 0.33 mg L-1, 0.1 mg L-1 and 0.033 mg L-1 at 2-week intervals. Geometric UVA dose series increasing by a factor of radical2 were used for the testing on the previously unexposed buttock skin. The MPD72 h was assessed at 72 h from the bath.

RESULTS

For the highest TMP concentration of 0.33 mg L-1, the median MPD72 h was 0.14 J cm-2 (95% confidence interval (CI), 0.10-0.14 J cm-2). For the diluted TMP bath concentration of 0.1 mg L-1, the median MPD72 h increased to 0.29 J cm-2 (95% CI, 0.2-0.41 J cm-2) and for 0.033 mg L-1 to 0.81 J cm-2 (95% CI, 0.57-1.15 J cm-2), respectively. Thus, diluting the labelled concentration of 0.33 mg L-1 1 : 10 increased the median MPD72 h 5.6-fold.

CONCLUSIONS

With regard to the safety and practicality of the TMP bath PUVA, the lower concentrations of TMP may be of clinical importance, and this needs to be validated in future controlled clinical trials.

Carcinogenic risk of bath PUVA in comparison to oral PUVA therapy

The potential carcinogenic risk of bath PUVA therapy was compared to that of systemic (oral) PUVA. An analysis of the epidemiological data on cancer risk following bath PUVA with trimethylpsoralen does not support the conclusion that bath PUVA per se is less carcinogenic than systemic PUVA with 8-methoxypsoralen (8-MOP). Pharmacokinetic studies indicate that both the concentration of 8-MOP in the target organ for PUVA carcinogenicity (skin) at the relevant time point (time point of UVA irradiation) and the extents of biological effects in the skin are comparable following bathwater or systemic 8-MOP administration. Furthermore, the therapeutic effects of PUVA arise from the same photochemical reaction mechanisms as do the carcinogenic effects. Theoretically, the ratio of (desired) cytotoxic versus (undesired) mutagenic effects could increase with increasing efficiency of the PUVA therapy itself. On the basis of the available evidence, it is concluded that all forms of PUVA therapy, independently of the route of 8-MOP administration, contribute to a small but dose-dependent increase in nonmelanoma skin cancer risk.

An open clinical trial of a new mouth-PUVA variant in the treatment of oral lichenoid lesions

OBJECTIVE

To investigate the feasibility of topical psoralen PUVA (sensitization in photosensitizing psoralen drug + UVA radiation) treatment of oral lichenoid lesions (OLL).

STUDY DESIGN

A total of 16 patients with OLL were treated using a 0.01% trioxsalen ointment and UVA doses in the 0.09 to 1.80 J/cm2 range. The average number of sessions was 8.7 and a mean cumulative irradiation dose was 4.25 J/cm2.

RESULTS

A marked-to-complete healing occurred in 3 to 16 (19%) patients immediately after therapy, in 4 of 14 (29%) after 3 months, and in 5 of 14 (38%) after 14 months, respectively. Of the 16 subjects with OLL, five were diagnosed as oral lichen planus (OLP) and 11 were classified as oral lichenoid reaction (OLR). Post-PUVA amelioration rate in patients with genuine OLP (4 of 5, 80%) was superior to that in patients with OLR (1 of 9, 11%).

CONCLUSION

Topical trioxsalen photosensitization can be used in mouth-PUVA treatment, and lichen planus is a main indication for this therapy.

Bath PUVA--an investigation of the distribution of trioxsalen (TMP) and 8-methoxypsoralen (8-MOP) in bathwater

Trioxsalen (TMP) bath PUVA avoids the side effects of nausea and headache associated with oral 8-methoxypsoralen (8-MOP) treatment and allows shorter irradiation times that can be advantageous in some patients. However we noted that a number of patients developed unusual patterns of phototoxic burning. We thought that this was related to an uneven distribution of the TMP in the bathwater and for this reason, a study of bath water TMP concentrations achieved using different TMP preparations was undertaken. The distribution of 8-MOP in an 8-MOP bath was also measured for comparison. Our results confirm that an uneven distribution of TMP is achieved using TMP capsules or suspension and would explain our observed patterns of burning. With an ethanolic solution of TMP, or the commercial equivalent Tripsor, or with Puvasoralen-8 (an 8-MOP preparation), a homogeneous psoralen distribution is achieved, and they are therefore preferable for use in bath PUVA.

A new psoralen-containing gel for topical PUVA therapy: development, and treatment results in patients with palmoplantar and plaque-type psoriasis, and hyperkeratotic eczema

Topical photochemotherapy with psoralen and its derivatives 4,5',8-trimethylpsoralen (TMP) and 8-methoxypsoralen (8-MOP), with UVA irradiation, was evaluated with regard to minimum phototoxic dose, concentration, timing of UVA irradiation and systemic and local side-effects, in healthy volunteers. Psoralen (0.005%) in aqueous gel was found to be superior to TMP and 8-MOP in aqueous gel. No hyperpigmentation was seen after topical PUVA treatment with psoralen in aqueous gel. Patients with plaque-type psoriasis (n = 7), palmoplantar psoriasis (n = 7) and hyperkeratotic eczema (n = 2) were treated. Topical PUVA therapy was effective in most psoriasis patients, without the occurrence of local or systemic side-effects. Moreover, hyperkeratotic eczema patients who did not respond to conventional therapy showed partial remission. These results indicate that topical PUVA therapy with psoralen in aqueous gel is a useful therapeutic modality for treatment of psoriasis patients, and patients with recalcitrant dermatoses such as palmoplantar psoriasis and hyperkeratotic eczema.

Oral photochemotherapy in vitiligo: follow-up, patient compliance

BACKGROUND

Vitiligo is a common, acquired condition of unknown etiology. The only practical treatment for patients with vitiligo is psoralen ultraviolet A (PUVA). No satisfactory method is available to measure the influence of certain factors on the therapeutic response.

METHODS

Twenty-nine patients with generalized vitiligo were studied for the effectives of PUVA therapy. The comparative study revealed the importance of certain variables (i.e., the proper dose of psoralen, the regular attendance of the patient, and the duration of the treatment). A scoring system had been designed and employed to evaluate these factors.

RESULTS

The follow-up of these patients showed that 18 of the 29 completed their treatment. An almost total improvement was obtained in 67% of these patients within 12 months (range 6-18 months). The average number of exposures was 64. A statistically significant difference was obtained between patients with good compliance and those with poor compliance.

CONCLUSIONS

The scoring system is a simple practical measure applicable to patients that proved eventually to be very useful for providing more effective treatment and a good response.

Comparison of the carcinogenic potential of trioxsalen bath PUVA and oral methoxsalen PUVA. A preliminary report

BACKGROUND AND DESIGN

There is an increasing concern about the long-term carcinogenic effect of oral psoralen with long-wave UV radiation in the A range (PUVA). Most follow-up investigations indicate a definite risk of squamous cell carcinoma of the skin with long-term PUVA treatment. In a recently published study of 4799 Swedish patients who had received PUVA, it was noted that 833 patients who had received trioxsalen bath or oral trioxsalen did not show any increased risk of skin cancer in contrast to oral methoxsalen. This finding has been further investigated in this study. We compared four dermatologic university clinics in Sweden with regard to the carcinogenic potential of the PUVA regimen used. One clinic used trioxsalen bath PUVA exclusively and the other three used oral methoxsalen. Information on their PUVA-treated patients was collected and linked with information from the Swedish Cancer Registry to identify individuals with squamous cell carcinoma of the skin.

RESULTS

A total of 18 squamous cell carcinomas of the skin were reported in 2975 PUVA-treated patients until 1987. The expected number was 3.1. The center using bath PUVA only had no increased risk of squamous cell carcinoma of the skin in contrast to the three centers using oral methoxsalen-PUVA. The increased risk for male subjects from those centers varied from six to 13 times that in the general population, but for female subjects a significant increased relative risk was found only at one center.

CONCLUSION

In this preliminary report, PUVA treatment with trioxsalen bath seems to be less carcinogenic than the oral dosage. However, differences in the patient populations might also have affected the outcome of the study. More information on this field is needed.

Study of the skin concentrations after administration of the various phototoxic drugs

The skin concentrations of 8-methoxypsoralen (8-MOP), 5-methoxypsoralen (5-MOP), and 4, 5', 8-trimethylpsoralen (TMP) were studied in the guinea pig following oral administration and bathing. The skin concentration of phototoxic drugs after oral administration peaked at 1.5 hours, and the concentration of 8-MOP was 3.5 times greater than that of 5-MOP. The skin concentration of TMP was not detected in our study (limit of sensitivity 5ng/ml). The skin concentrations of phototoxic drug after bathing decreased in the order of 5-MOP, TMP, and 8-MOP.

The effect of UVA irradiation on the epidermal melanocyte after 8-MOP and TMP administration

Morphological and numerical changes in the epidermal melanocytes of black C57BL mice after phototoxic drug administration followed by ultraviolet A irradiation were studied to compare the effects of photochemotherapy on the epidermal melanocytes using 8-methoxypsoralen and trimethylpsoralen. One hour after intraperitoneal injection of the phototoxic drugs, 1.5 mg/kg in the small dose group and 6.0 mg/kg in the large dose group, the mice were exposed to UVA irradiation. This procedure was performed twice a week for 8 weeks at the small dose group and for 5 weeks in the large dose group. Skin biopsies were taken before irradiation in both groups, and follow up biopsies were done at each week. The number and size of the melanocytes were observed in a split-DOPA preparation. In the drug treated groups, there was an increase in the size of the perikaryon, and the number, length, width, and arborization of dendrites. Such changes were more clearly seen in the group treated with trimethylpsoralen compared with the 8-methoxypsoralen treated group. Therefore, trimethylpsoralen is more effective than 8-methoxypsoralen in the increase of the perikaryon size, and the number, length, width, and arborization of dendrites of melanocytes in the intraperitoneal injection.

Multiplicity reactivation and mutagenesis of trimethylpsoralen-damaged herpes virus in normal and Fanconi's anaemia cells

Fanconi's anaemia (FA) cells are hypersensitive to the lethal effect of DNA cross-linking compounds. Herpes simplex virus (HSV) has been used here as a probe to monitor in FA cells repair of psoralen damage of which cross-links are a part. The replication of HSV is impaired when its DNA contains covalently photobound psoralen molecules. In comparison to other psoralens, 4,5',8-trimethylpsoralen (4,5',8-TMP) is one of the most photoreactive psoralens and it forms a relatively high proportion of DNA interstrand cross-links. TMP-damaged HSV is efficiently reactivated by multiple infection in human fibroblasts. The extent of multiplicity reactivation is greater in cells from FA donors (five strains tested) than in normal cells (three strains). Mutagenesis studied in the viral thymidine kinase locus revealed that: (i) spontaneous viral mutation rate is lower in FA than in normal cells; and (ii) under conditions of multiple infection, the mutation rate is either greater (normal cells) or unchanged (FA cells) in the progeny from psoralen-damaged HSV compared to that from untreated virus. Taken together, these observations suggest that the pathway underlying multiplicity reactivation of psoralen-damaged HSV is error-free in FA cells relative to normal cells.

Concentration of trimethylpsoralen in blood and skin after oral administration

Trimethylpsoralen (TMP) concentrations were determined in blood and skin of 21 patients given oral TMP therapy and were compared to data obtained from 5 patients treated with TMP baths. The quantitative determination was performed by gas chromatography with selected ion monitoring. Concentrations of up to 5.6 ng/ml were detected in whole blood from orally TMP treated patients, with about the same concentrations in patients given TMP baths. Whole skin biopsies from patients ingesting TMP showed concentrations in 14 patients that ranged from 30 to 1250 ng/g skin, median value 85 ng/g. Large interindividual variations were observed. Stripped skin from 5 patients after TMP baths showed a somewhat higher median value of 160 ng/g and their entire skin had fairly high concentrations, with a median value of 390 ng/g, probably mostly bound to stratum corneum. Different concentrations in different parts of the skin may explain the difference in phototoxic capacity when the drug is given locally.

Receptor-mediated photo-cytotoxicity: synthesis of a photoactivatable psoralen derivative conjugated to insulin

4'-Aminomethyl-4,5',8-trimethylpsoralen has been chemically conjugated to insulin using a carbodiimide derivative. The psoralen moiety retains its photochemical reactivity as evidenced by its ability to crosslink DNA after exposure to long wavelength ultraviolet light (UVA, 320-400 nm). This chimeric molecule has been used to selectively kill a population of lymphocytes whose expression of insulin receptors has been stimulated with phytohemagglutinin. Insulin carries the psoralen into the cell via receptor-mediated endocytosis, where it is subsequently activated by exposure to UVA light. The UVA induced activity of AMT-insulin can be blocked by the presence of native insulin. The viability of unstimulated lymphocytes was not affected by AMT-insulin and UVA light. The hybrid insulin-psoralen molecule may be a prototype for a family of phototoxic drugs which can be selectively delivered to subsets of lymphocytes.

A study of the relationship between photosensitizing and therapeutic activity of 4,5',8-trimethylpsoralen, and its major metabolite 4,8-dimethyl, 5'-carboxypsoralen

The molecular basis for the clinically observed differences in the skin photosensitizing activity and therapeutic effectiveness of the topically applied and orally administered drug trimethylpsoralen (TMP) was investigated. TMP, when tested topically, is a very potent photosensitizing and therapeutically effective furocoumarin in the treatment of psoriasis. When administered orally, however, it is significantly less photosensitizing and therapeutically a less effective drug than the commonly used furocoumarin 8-methoxypsoralen. This decreased reactivity of oral TMP is attributable to its poor solubility and rapid in vivo metabolic transformation to several inactive (nonphotosensitizing) metabolites, one of which is referred to as 4,8-dimethyl,5'-carboxypsoralen (DMeCP). The supporting evidence has been obtained by: (a) isolation of the urinary metabolite DMeCP and subsequent comparison of its properties with the synthetically prepared DMeCP and its methyl ester; (b) examining the dark and photochemical interactions of TMP, DMeCP, and DMeCP methyl ester with DNA and determining their ability to form interstrand cross-links with DNA; and (c) studying the inhibition of DNA and RNA synthesis in Ehrlich ascites tumor cells and the killing of bacteria and T2 bacteriophages. The structure-activity relationship of TMP and DMeCP also has been examined in normal human subjects and in patients with psoriasis. The order of topical therapeutic effectiveness in terms of ability to clear psoriasis plaques appeared to be: TMP greater than 8-MOP greater than DMeCP methyl ester greater than DMeCP. The data also suggest the methyl ester of DMeCP to be an interesting nonphotosensitizing furocoumarin that photoconjugates to DNA better than 8-MOP and is therapeutically effective in psoriasis.

Determination of trimethylpsoralen in blood, ophthalmic fluids, and skin

Trimethylpsoralen (TMP) levels in the blood of vitiligo patients were determined through the use of a high-performance liquid chromatographic method. TMP was extracted from blood buffered at pH 9.0 with 95:5 (V/V) hexane-isopropanol mixture; evaporated to dryness, and reconstituted in 50 microliters of ethanol. A 10-microliters aliquot was injected into a Micropack MCH-10 column (Varian HPLC model #5000). The mobile phase consisted of a mixture of water and acetonitrile with a linear gradient. The retention time of TMP was 16.5 min. The calibration curve of the external standards was linear. Overall recovery of the internal stands was 75-92%, with the lower detection limit of TMP at 2 ng/ml. Peak blood levels as low as 140 ng/ml and as high as 800 ng/ml were obtained in vitiligo patients 1-2 hr following the oral administration of 30 mg of trioxsalen tablets (Paul B. Elder Co.). Blood TMP levels peaked consistently at 2 hr when patients were fasted for 8 hr prior to drug ingestion. These results are consistent with the clinical observation that maximum response due to phototherapy is obtained 1-2 hr after oral administration of the drug. Two hours after oral drug administration, TMP levels in the epidermis, dermis, and whole skin of the guinea pig (in ng per g tissue) were: epidermis, 226 +/- 15; dermis, 25 +/- 6; and whole skin 176 +/- 12. Also detected were TMP levels 244 +/- 17 ng/ml in aqueous humor and 63 +/- 6 mg/ml in vitreous humor. These results point to the fact that the eyes of patients must be protected from overexposure to sunlight after psoralen-ultraviolet treatment.

The effect of psoralens on hepatic and cutaneous drug metabolizing enzymes and cytochrome P-450

Psoralens are tricyclic furocoumarins with potent photosensitizing properties in the skin and are now widely used in the treatment of several dermatologic diseases. In this study the effect of 3 different psoralens 8-methoxypsoralen (8-MOP), 4,5',8-trimethylpsoralen (TMP) and isopsoralen on hepatic microsomal drug-metabolizing enzymes and cytochrome P-450 has been assessed in mice and rats. 8-MOP administered orally to CD-1 mice daily for 6 days caused 2-3 fold increases in hepatic aryl hydrocarbon hydroxylase (AHH), ethylmorphine N-demethylase and cytochrome P-450. The absorbance maximum of the induced cytochrome was at 450 nm. Aniline hydroxylase activity was unchanged. Chronic administration of 8-MOP to hairless mice caused significant enhancement of hepatic ethylmorphine N-demethylase and cytochrome P-450 but had no effect on AHH; whereas chronically administered TMP had no significant effect on any of these parameters. Isopsoralen and TMP administered orally to CD-1 mice daily for 6 days had no effect on any of these liver enzymes or on hepatic P-450. 8-MOP administered daily for 6 days to rats caused a greater than 4-fold enhancement of AHH and greater than 2-fold enhancement of ethylmorphine N-demethylase and cytochrome P-450. These studies indicate that orally administered 8-MOP induces hepatic drug-metabolizing enzymes and cytochrome P-450 to a lesser extent than do the barbituates and suggest that this drug could influence the rate of biotransformation of concomitantly administered drugs in patients undergoing PUVA therapy.

Serum levels of trimethylpsoralen after oral administration

Serum concentrations of trimethylpsoralen were determined for up to 5 h after oral administration in four patients with vitiligo. Measureable amounts of trimethylpsoralen were found in the serum only after administration of high oral doses (100 to 400 mg TMP).

Long-term local trioxsalen photochemotherapy in psoriasis

Good results were achieved in psoriasis with trioxsalen baths and UVA in 92% of 158 patients during initial treatment and in 83% of 139 patients during long-term treatment. Grade I-II local burns were encountered in about 7% of the patients. In addition, itchy skin pain was experienced by 2 patients, and in both of these the therapy was discontinued. Neither skin malignomas nor other serious side effects were seen.

Trimethoxypsoralen in vitiligo

The treatment of vitiligo has been unsatisfactory. Introduction of systemic furocoumarins to treatment regimens has given very promising results. Trimethylpsoralen has been found to be more potent than 8-methoxypsoralen. In cases studied, ultraviolet irradiation of affected sites following topical application of trimethylpsoralen was found to hasten the process of repigmentation. Simultaneous treatment of underlying disease produced a quicker response followed by sustained relief.

Treatment of psoriasis with trioxsalen baths and dysprosium lamps

Photochemotherapeutic treatment of psoriasis with trioxsalen baths (0.5 mg/1) for 15 minutes followed by irradiation with dysprosium lamps (Osram HQI-TS) healed or nearly healed the psoriatic lesions in 18 patients within 3-5 weeks. A control area treated with the Ingram method showed a slower healing in 9 of these patients. Methoxsalen bath was not as effective in healing at the concentration used (1 mg/l). The bath method is easy to administer and cosmetically acceptable. Sensitisation to light is maximal immediately after the bath and disappears more quickly than after painting with an alcoholic trioxsalen solution. By using baths, there is less risk of accidental burns or uneven pigmentation than with the often time-consuming local application of psoralen solutions. Toxic systemic effects, which are possible with oral treatment, are less apt to occur. The dysprosium lamps give high intensity in the UV-A region. Exposure times of 10 seconds to 8 minutes are effective in the treatment of psoriasis, where both the UV-B region itself and the UV-A in combination with trioxsalen have psoriasis-healing properties.