Chapter 237

Phototherapy
Jennifer A. Cafardi, Brian P. Pollack,
& Craig A. Elmets

DISEASES AMENABLE TO
PHOTOTHERAPY
Phototherapy and Psoriasis
BROADBAND UVB AND NARROWBAND UVB.
Both BB-UVB and NB-UVB have been employed
to treat psoriasis. Their presumptive mechanisms
of action in this disease include its effects on DNA,
antimicrobial actions which may alter the microbial
flora of the skin,111 induction of anti-inflammatory
and immunosuppressive cytokines,112114 augmentation of vitamin D levels,115116 alterations in antimicrobial peptides,116 and a reduction in C-reactive
protein.117
Clinical trials38 supporting the research findings41
that the wavelengths most effective at clearing psoriasis are in the range of 313 nm have led to broad
utilization of NB-UVB for psoriasis (eFig. 2370.1).
NB-UVB has thus become first-line therapy for
chronic plaque psoriasis, considered to be superior
to conventional broadband UVB with respect to
both clearing and remission times.38,118 The difference in efficacy may be related to more efficient
clearing of T cells by NB-UVB from the epidermis
and dermis of psoriatic plaques compared with
conventional broadband UVB.20 The endpoint of
phototherapy is complete clearance of all psoriatic
skin lesions. Psoriasis, however, is a chronic disease
and the remission induced by UVB phototherapy
is often short lived. In a randomized, prospective,
multicentered trial, investigators found that continuing UVB phototherapy after initial clearing contributes to the control of the disease and is justified
for many patients.119 In such maintenance therapy,
the frequency of UVB treatments is reduced while
maintaining the last dose given at the time of clearing. NB-UVB can be used safely in pregnancy and in
children.
Other agents (topical and oral) combined with
UVB phototherapy may clear psoriatic skin lesions
in a shorter period of time. Combined therapies
may thus allow for fewer treatments and potentially
less photoaging and other risks. Often combination

regimens are administered when phototherapy

alone is no longer effective. Oral retinoids, such as
acitretin,120 increase efficacy, particularly in patients
with chronic plaque type psoriasis.121123 Although
fewer sessions may be required with this combination therapy, the rate of relapse may be slightly
higher. Methotrexate (15 mg/week) administered
3 weeks before starting NB-UVB can also allow for
quicker results in fewer phototherapy sessions.124
More recently, biologic therapies have been evaluated in conjunction with phototherapy. Treatment
with NB-UVB significantly accelerated the clearance
of psoriatic lesions in patients responding slowly to
etanercept.125 Other studies have evaluated alefacept in combination with NB-UVB and have shown
improved and more rapid clearance of psoriatic
lesions.126
Phototherapy is commonly combined with topical
agents in order to achieve higher clearance rates,
longer disease-free intervals, and a lower risk of
side effects. The Goeckerman regimen consists of
the application of tar-containing topical agents
with subsequent UV irradiation. The use of liquid
carbonis detergens with NB-UVB is one example of
a modified form of this regimen. The regimen has
been shown to be safe, convenient, effective, and
leads to more rapid improvement of psoriasis than
light therapy alone.127 The antipsoriatic vitamin D
analogs calcipotriol and calcitriol, used in conjunction with NB-UVB, provide additional benefit
compared to either the drugs or the phototherapy
alone.128133 A combination of calcipotriol with
phototherapy leads to degradation of vitamin D3,
and calcipotriene has been shown to increase the
minimal erythema dose in patients, suggesting that
it has a photoprotective effect.134 For these reasons,
when used in combination with phototherapy, vitamin D analogs are applied after the light treatment.
Tazarotene 0.1% gel has an additive or synergistic
effect when combined with NB-UVB.135 Because
retinoids can cause photosensitivity, it is common
practice to initiate phototherapy at somewhat
lower doses when tazarotene is used with UVB.136
Topical bexarotene gel 1% has also been combined
with NB-UVB for the treatment of psoriasis and
been shown to have greater efficacy than either
alone.137 By decreasing scatter from scales in the
stratum corneum, lubricants improve transmission
of UVB, and a combination of topical lubricants
with UVB therapy increases efficacy.138140 The use
of topical salicylic acid with UVB has not been
found to increase the efficacy of UVB phototherapy
because it blocks UVB penetration.

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344 Chapter 237: Phototherapy

TARGETED PHOTOTHERAPY.
Targeted phototherapy using a monochromatic
308-nm excimer laser or monochromatic excimer
light is effective and safe for psoriasis. A large, multicenter study found that fewer patient visits were
required with targeted phototherapy compared to
conventional phototherapy.141 The use of monochromatic excimer compared to cream PUVA has
been found to have equivalent efficacy for palmoplantar psoriasis.142
PUVA PHOTOCHEMOTHERAPY.
Oral PUVA has been shown to consistently induce
remission of psoriasis in clinical studies.65,143,144
At least 75% improvement in PASI score can be
expected after 12 weeks of PUVA treatments in
60% of patients.143 In some studies, oral PUVA has
been observed to be more efficacious in clearing
plaque psoriasis than NB-UVB, and the duration of
remissions is more prolonged,144 while other studies
have found the two treatments to be comparable,
particularly when NB-UVB is used three times a
week.145148 It must be noted here that unlike drug
administration, the success of PUVA and phototherapy generally depends in large part on physiciandetermined patient-specific subtle modifications of
the regimen, such as the dose increments between
treatments, that optimize therapeutic response
while avoiding burns or other adverse effects.
Hence, the response to phototherapy may vary
greatly among studies and among practitioners.
Repeated exposures are required to clear PUVAresponsive diseases, with gradual dose increments
as pigmentation develops. Upon clearing, patients
are often transitioned to maintenance therapy, during which the frequency of treatments is gradually
reduced. There are various maintenance algorithms.
One regimen consists of 1 month of twice-weekly
treatments, at the last UVA dose used for clearing,
followed by another month of once-weekly exposures. Other protocols recommend maintenance
treatment only when the patient relapses rapidly.
This has the advantage of avoiding higher cumulative exposure and thus greater risk of long-term
side effects.
A combination of PUVA and methotrexate can
reduce the duration of treatment, number of exposures, and total UVA dose required for clearing and
is also effective in clearing patients unresponsive to
PUVA alone.149 This combination appears to be safe

if used during the clearing phase. However, longterm methotrexate, defined as 36 or more months
of use, in combination with PUVA may increase the
risk of lymphoma.87
The combination of cyclosporine with PUVA is not
recommended because of the greatly increased
risk of squamous cell carincoma.78 There are no
published clinical trials combining PUVA with the
biologic agents.
PUVA therapy is more efficacious when combined with a daily oral retinoid (etretinate, acitretin,
isotretinoin; 1 mg/kg), a treatment regimen that has
been referred to as RePUVA. The addition of an oral
retinoid can bring patients into remission, even if
they have not responded to PUVA alone.150 The oral
retinoid is typically administered 510 days before
initiating PUVA, and is continued throughout the
clearing phase. RePUVA often is able to reduce the
number of PUVA exposures by one-third and the
total cumulative UVA dose by more than one-half.
Oral retinoids when combined with PUVA have
been shown to reduce the risk of SCC by 30%, although it does not alter the incidence of BCC.79 The
mechanism of the synergistic action of retinoids
and PUVA is unknown, but has been postulated to
result in part from accelerated desquamation that
optimizes the optical properties of the skin.
Topical tazarotene gel 0.1% combined with oral
PUVA accelerates the response to treatment.151 This
may decrease exposure to UVA and thus the longterm hazards associated with PUVA therapy. Due
to the photosensitizing effect to tazarotene, it is
recommended PUVA therapy be initiated at slightly
lower doses than usual.136 The tazarotene plus PUVA
bath therapy is also clinically and statistically superior to vehicle plus PUVA bath therapy.152
The application of salicylic acid in petrolatum just
before PUVA therapy is not recommended as it may
hinder the penetration of UVA.153 When calcipotriol
is used with PUVA, it should not be applied within 2
hours of phototherapy.
TOPICAL AND BATH-PUVA FOR PSORIASIS.
Application of 8-MOP in creams, ointments, or
lotions followed by UVA irradiation is effective in
clearing psoriasis, but may result in nonuniform
distribution on the skin surface. This may induce
unpredictable phototoxic erythema reactions and
irregular patches of cosmetically unacceptable
hyperpigmentation. Furthermore, the application

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Chapter 237:

of the medication is potentially labor intensive. For

these reasons, topical psoralens are used most commonly for limited plaque psoriasis and palmoplantar disease.

Phototherapy and Atopic

Dermatitis
NARROWBAND UVB.
Studies evaluating NB-UVB as a treatment for severe atopic dermatitis have shown that it improves
severity scores, reduces potent topical steroid use,
and provides a long-term benefit for the majority
of patients.154157 Compared with bath PUVA using
half-body UVB versus UVA comparisons, both
NB-UVB and bath-PUVA were both highly effective.
Most patients, however, preferred NB-UVB. Relief of
pruritus usually occurs in the first 2 weeks, prior to
the visible resolution of the cutaneous lesions.158
Additionally, improvements can be maintained
months after phototherapy has been stopped. NBUVB has been used sequentially following cyclosporine, to avoid relapse of disease.159
There is little information regarding the use of NBUVB in children, and long-term data on the safety
of this therapy are still needed. However, those
studies that have examined NB-UVB for atopic
dermatitis and other skin diseases in children have
found that it is well tolerated and produces excellent responses with no serious side effects.160163
When side effects are mentioned, erythema is the
most common161; other adverse reactions, such as
herpes simplex reactivation, are rarely reported.162
In some cases, UVA combined with NB-UVB appears
to provide added benefit.164
Long-term studies in animal models evaluating
the carcinogenic potential of tacrolimus (0.03%
and 0.1%) and pimecrolimus 1% did not find an
increase in the incidence of UV-induced skin tumor
growth.165 However, there is an increased risk of
cutaneous cancers in the organ transplant patients
treated with systemic tacrolimus. Currently available
long-term follow-up with topical tacrolimus and
pimecrolimus is lacking. For these reasons, combining phototherapy with topical calcineurin inhibitors
for atopic dermatitis is not recommended.166
EXCIMER LASER AND ATOPIC DERMATITIS.
The 308-nm xenon-chloride monochromatic excimer light has been evaluated in localized atopic
dermatitis and has been shown to be efficacious

Phototherapy 345

in reducing the severity of the skin disease, and

diminishing pruritus with lasting results.61,167169
In extensive atopic dermatitis, this treatment is
impractical, but it is particularly useful for atopic
dermatitis involving the hands,61 and in situations
in which there is an interest in limiting the use of
topical steroids.
PUVA.
Oral PUVA has been found to be highly effective for
the treatment of atopic dermatitis.170173 In contrast
to its use in psoriasis, the number of treatments
for clearance of atopic dermatitis may be relatively
high. Additionally, a rebound effect may occur in
a high percentage of patients if the phototherapy
is not combined with other therapies or if maintenance therapy is not instituted.170 Bath PUVA is
also used for atopic dermatitis, primarily in Europe,
and has been shown to be a very effective treatment.174176
UVA1.
UVA1 phototherapy is a highly effective, nonsteroidal, therapeutic alternative for treatment of acute
exacerbations of atopic dermatitis and is almost
devoid of uncomfortable side effects.46,5152,54 Doses
of UVA1 (60130J/cm2 per day) over a 3-week period of time have been shown to reduce the clinical
severity of atopic dermatitis. However, effectiveness
is short term and is followed by recurrence of symptoms in the majority of patients.53,177 In one study,
NB-UVB provided a greater therapeutic effect than
UVA1 for chronic atopic dermatitis.178

Phototherapy and Cutaneous T

Cell Lymphoma
PUVA.
PUVA (photochemotherapy with UVA) has been a
successful therapeutic option for cutaneous T cell
lymphoma (CTCL) since the 1970s.179180 Complete
clearing may be induced when malignant cells
are confined to the epidermis and the superficial
dermis, within the depth of UVA penetration. For
the clearing phase, treatment schedules and dosimetry are essentially the same as for psoriasis. The
treatment consists of three phases: (1) a clearing
phase, (2) a maintenance phase, and (3) monitoring
therapy. Maintenance therapy is not standardized;
patients benefit most from individualized schedules.181 Therapy is discontinued after a variable

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346 Chapter 237: Phototherapy

period and patients are monitored. Relapses tend

to respond as well as the initial lesions when PUVA
is resumed. Patients with tumor-stage CTCL (IIB)
or greater exhibit a high rate of early recurrences,
which require permanent maintenance treatment.
In these stages, PUVA typically is combined with
other modalities in order to produce complete
responses. Prolonged remissions have been observed with combinations of PUVA with interferon
-2a182 and with low-dose IFN- 2b.183 In later stages
of CTCL, PUVA has been employed as a palliative
treatment, reducing the tumor cell burden and
acting synergistically with other treatments.184 For
example, there has been success combining PUVA
and oral bexarotene for the treatment of advanced
CTCL (Sezary syndrome).185
Bath-water PUVA therapy with 8-MOP is a valuable
phototherapeutic alternative, which can be considered for patients in whom systemic psoralen cannot
be used. Excellent responses have been reported in
patients with early stage mycosis fungoides186 and
in children.187
NARROWBAND UVB.
NB-UVB may be as effective as PUVA for early stage
CTCL.188196 Some authors have advocated starting
with NB-UVB due to a more favorable safety and
side effect profile.189 Clinical remissions are reported
to last for 3194 to 24.5189 months; maintenance tends
to prolong remission.195 NB-UVB has also been used
in conjunction with oral bexarotene with success.197

Phototherapy of Vitiligo
PUVA and NB-UVB are two of the leading treatments for vitiligo. When employed for vitiligo,
NB-UVB is typically administered three times per
week.198 The earliest sign of response to therapy is
perifollicular repigmentation. Cosmetically acceptable treatment success, defined as greater
than or equal to 75% repigmentation, has been
achieved in 12.5%199 to over 75%200201 of patients.
Factors that predict how a patient will respond to
NB-UVB include Fitzpatrick skin phototype, the
areas treated,200206 and the type of vitiligo.202 There
does not appear to be an association between
response to treatment and patients sex, age, family history of vitiligo or the extent of body surface
area involved.205207 Patients who show early initial
repigmentation are more likely to have a higher
percentage of final repigmentation.199,205 Whether

the duration that an individual has had vitiligo

influences the response to therapy is controversial.
In some studies, the greater the length of time
between onset of vitiligo and initiation of NB-UVB,
the less successful the repigmentation.196,198,200202
However, in other studies, the duration of vitiligo
had no influence on the efficacy of NB-UVB.207208
In individuals with Fitzpatrick skin types IV and V,
vitiliginous areas have been noted to repigment
slightly darker than the surrounding skin. This
resolves after a few months, resulting in a cosmetically acceptable outcome.198,205
Although data are somewhat limited, relapse
rates may be anywhere from 25% to 84% after 1
year.205,208209 Those who relapse tend to respond to
another course of phototherapy. Pseudocatalase
cream has been used in conjunction with NB-UVB.
Whether pseudocatalase increases the efficacy of
NB-UVB is controversial.210211
Targeted phototherapy with a 308-nm excimer
laser has also been reported to be effective in
vitiligo.212215 Sessions are performed two to three
times weekly, with the ultimate rate of repigmentation dependent on the total number of sessions
rather than the frequency.216217 The treatments are
well tolerated, and side effects are minimal. Similar
to standard NB-UVB therapy, lesions on the face,
neck, and trunk respond better than those on the
extremities. The hands and feet have the least favorable outcome.212,215,218221 Monochromatic excimer
light (MEL) has also been effective in patients with
vitiligo, even if they have not previously responded
to NB-UVB.37
Although PUVA was first used for vitiligo, it is used
less commonly for that indication with the introduction of NB-UVB. Responses have been achieved
in up to 70% of patients.222 Combination therapy of
UVA and a medium potency topical corticosteroid
is three times more effective than either treatment
alone.223 In contrast to NB-UVB and PUVA, UVA-1
does not cause repigmentation and only accentuates the difference in color between normal and
vitiliginous areas by tanning the normal skin.

Sclerotic Skin Disease

LOCALIZED AND SYSTEMIC SCLERODERMA.
UVA1 has been reported to decrease lesional skin
thickness, improve skin elasticity, reduce sclerotic
plaques and increase passive range of motion in

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Chapter 237:

localized scleroderma (eFig. 2370.2).50,224225 There

have been varying opinions as to the best dose
and treatment regimen.226228 In most studies, UVA1
has been administered at a dose of 60130 J/cm2
five times per week, although lower doses (20 J/
cm2) have been also reported to be effective. When
doses of 20 J/cm2 and 70 J/cm2 were compared, the
higher dose was more effective.226 However, when
130 J/cm2 was administered three times per week,
the tanning response produced by the UVA1 treatments interfered with its ability to soften the sclerodermatous patches, implying that less frequent
treatments would be more effective.228
The mechanism of action is at least in part
through induction of matrix metalloproteinase-1,229
and downregulation TGF- through the SMAD gene
pathway.230232 UVA1 has been shown to downregulate human -defensin, interleukin-6 and 8, and
this correlates with clinical improvement.233 UVA1
has also been used to treat acrosclerosis in patients
with systemic scleroderma.234 Marked improvement
has been noted with softening of affected skin and
increased finger movement.
Oral and topical PUVA have also been used for this
disease with improvement in range of motion and
contractures,235 and oral PUVA has been used for
disabling, extensive morphea in children.236239
GRAFT-VERSUS-HOST DISEASE.
In chronic graft-versus-host disease (GVHD), NBUVB has been employed as a second line treatment
in children240 and adults241 who are resistant to or
have relapsed on standard immunosuppressive
regimens. Oral PUVA,242246 topical PUVA247248 and
UVA1249251 have also been employed. Bath PUVA
in combination with isotretinoin is another option
for sclerodermoid GVHD.252 If phototherapy is to
be employed for these patients, it is important to
examine them regularly, since they already have an
increased risk of skin cancer because of their immunosuppressive therapies.
OTHER SCLEROTIC SKIN DISEASES.
UVA1 has led to modest improvement in the degree
of induration, and, at times, in mobility of the hands
and legs in nephrogenic systemic fibrosis.253254 Total
treatments have ranged from 22 treatments (with
a cumulative dose of 1,855 J/cm2) to 50 treatments
(3,850 J/cm2). There are also anecdotal reports of its
use in scleredema, vulvar lichen sclerosis and stiff
skin syndrome.49

Phototherapy 347

Pruritis
Phototherapy is an option for the pruritus associated with chronic renal failure. About 80%90% of
patients improve within 25 weeks.255257 If symptoms recur, they commonly respond to retreatment
with UVB. For this disorder, phototherapy works on
a systemic level rather than locally, because BB-UVB
exposure to one-half of the body improves pruritus in both the exposed and unexposed sites.258
Some patients respond well to BB-UVB, and are less
responsive to NB-UVB.259
Phototherapy has been considered by some to be
the most effective treatment for cholestatic pruritus.260262 UVB phototherapy has also been combined with cholestyramine.263
PUVA has resulted in improvement in aquagenic
pruritus in a number of patients, but maintenance
treatments may be required.264266
Reports of successful treatment with NB-UVB
three times a week,267 UVA in combined with UVB,268
and PUVA269271 have been reported to improve the
pruritus associated with polycythemia vera.
NB-UVB and BB-UVB and PUVA have all been used
safely and effectively to treat eosinophilic folliculitis
in HIV-positive patients.272276

Photodermatoses
NB-UVB277279 and oral PUVA280281 is a useful method for preventing outbreaks of moderate-to-severe
polymorphous light eruption (PMLE). Hardening is
obtained by exposing the individual to low levels
of phototherapy while, at the same time, placing them prophylactically on oral corticosteroids
in order to prevent lesions. The mechanisms by
which phototherapy induces tolerance to sunlight
include thickening of the stratum corneum, hyperpigmentation and cutaneous immune modulation.
Although NB-UVB is currently used more commonly
than PUVA, PUVA has the advantage of a rapid and
intense pigment induction at relatively low UVA
doses that usually remain well below the threshold
for eliciting an outbreak. Approximately 10% of patients will develop typical PMLE lesions during the
initial phase of PUVA, but these usually disappear
with continued treatment. Phototherapy is typically initiated 1 month before the first anticipated
intense sun exposure, such as a sunny midwinter

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348 Chapter 237: Phototherapy

vacation. Once hardening has been induced, it

must be maintained by frequent exposure to ambient sunlight.
Lesions of solar urticaria can also be prevented
with phototherapy. The regimen involves induction
of tolerance by repeatedly exposing the patient to
graded doses of the causative wavelengths.282284
Successful treatment has been achieved with
repeated exposures to UVA or PUVA.282,284286 PUVA
may result in a response of greater duration. A
condensed type of phototherapy called rush
hardening has also been used.287 In rush hardening, patients are exposed to quarter- or half-body
UVA irradiation at 50% of the determined minimal
urticarial dose (MUD) with hourly increases in body
surface area irradiation and dose.287 Hardening or
desensitization has been reported to occur in as
few as 3 days. The most important parameter in
rush hardening is to determine the MUD and action
spectra immediately before starting therapy and
initiating the treatment at a dose lower than the
MUD in order to minimize exacerabations.288 The
disadvantage of this modality is that tolerance is
lost quickly if the treatments are not continued every few days. For unexplained reasons UVA1, which
has effects on mast cells, is not particularly effective
in preventing solar or other forms of urticaria.
Chronic actinic dermatitis and actinic prurigo are
other photosensitive disorders that have been reported to benefit from controlled, low-doses of UV
irradiation.289291 In contrast to PMLE, an extended
duration of treatment is often required for chronic
actinic dermatitis.

Other Diseases
LICHEN PLANUS.
Narrowband UVB therapy has been used for recalcitrant lichen planus and is typically administered 3
times weekly on nonconsecutive days. A complete
response in 70% of patients has been reported after
an average time of 10 weeks.292294 Improvement in
the pruritus can be expected before disappearance
of skin lesions. Oral and topical PUVA295 are other
alternatives. In general, lichen planus tends to be
more resistant to PUVA than psoriasis when treated
with a similar schedule. A regimen of RePUVA may
accelerate clearing, but has been reported to cause

transient hyperpigmentation.296 NB-UVB produces

similar outcomes, but some have reported a better
initial clinical response with PUVA.297 Follow-up
of patients that have cleared on PUVA has shown
that the disease tends to recur, raising the possibility that the treatment may prolong the disease.295
Although exceedingly rare, PUVA has been reported
to induce lichen planus298 and lichen planus pemphigoides299 in patients undergoing the therapy for
other skin diseases.
CHRONIC HAND ECZEMA.
NB-UVB and local bath-PUVA have been successful
for the treatment of dyshidrotic eczema.300302 and
chronic palmoplantar eczema. Bath PUVA may be
less effective in smokers with dyshidrotic eczema.303
Oral PUVA has been found to be preferable for patients with hyperkeratotic eczema and bath PUVA is
more beneficial for dyshidrotic eczema,304 although
oral PUVA is effective for dyshidrotic eczema as
well.305
Localized UVA1 has also been used for dyshidrosis.306307 and is comparable to cream PUVA for
chronic vesicular dyshidrotic eczema.306 Because
the long-term effects of UVA1 are unknown, it has
been recommended that courses of localized UVA1
phototherapy be performed no more than twice
annually.
PITYRIASIS LICHENOIDES.
NB-UVB and BB-UVB have been shown to be
safe and effective for both pityriasis lichenoides
chronica (PLC)308309 and pityriasis lichenoides et
varioliformis acuta (PLEVA).310 A complete response
has been reported to occur with NB-UVB in 65% of
PLEVA patients and a partial response in the rest.310
NB-UVB also led to a complete response in over
85% of PLC patients.
LYMPHOMATOID PAPULOSIS.
Oral PUVA has been used for patients with lymphomatoid papulosis (LyP),311312 but relapse may occur
upon cessation of therapy.312 Bath PUVA has been
effective in LyP in children.313314 Some patients
have also responded to targeted phototherapy with
the 308-nm excimer laser.315 UVA1 (60 J/cm2) has
also been employed,316 but relapses are common.

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Chapter 237:

TELANGIECTASIA MACULARIS ERUPTIVE

PERSTANS.
Oral PUVA is reserved for telangiectasia macularis
eruptive perstans (TMEP) patients with severe
disease, because other therapies such as laser treatment may be safer long term and the response is
often temporary.317319
URTICARIA PIGMENTOSA.
UVA1 phototherapy ameliorates both the objective
and subjective symptoms of urticaria pigmentosa
in adult patients, and long-term remission can be
achieved in many cases.21,320321 Although lesions
may not respond completely with UVA1 therapy,
the symptoms of pruritus are often relieved. Urinary
histamine levels also decrease in response to UVA1.
In some patients, systemic manifestations such as
diarrhea and migraine headaches have also been
reported to improve. In one patient with bone
marrow infiltration, mast cell numbers decreased
continuously after high-dose UVA1, which may
have resulted from modulation of soluble cytokine
production by UVA1 treated skin.21 PUVA does not
decrease mast cell numbers, and this may explain
its limited benefit in many patients.322
GRANULOMA ANNULARE.
Patients with widespread granuloma annulare
treated with PUVA have had complete clearance of
their disease.323 Maintenance therapy may result in
prolonged disease-free intervals. Bath and cream
PUVA have also been reported to be useful for
granuloma annulare.324326 Although the mechanism of action of PUVA in granuloma annulare is unclear, selective elimination of pathogenic cells may
be one explanation. UVA1 phototherapy provides
good or excellent results in the majority of patients,
but discontinuation of treatment is followed by
early recurrence of disease.327
PERFORATING DISORDERS.
There has been some success in treating perforating disorders with NB-UVB phototherapy.328 There
are anecdotal reports that PUVA329 is effective as
well. Patients are treated two to three times weekly
with clearing of lesions and symptoms after ten
to fifteen treatments. The mechanism by which
improvement occurs is unknown.

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Phototherapy 349