Minimising the Risks of PUVA Treatment

Abstract

Psoralen photochemotherapy (PUVA) is a combination of orally administered psoralen and long wave ultraviolet-A radiation (UVA), and is one of the most effective forms of therapy for psoriasis. The unwanted effects of PUVA therapy can be divided into short and long term adverse effects. The short term adverse effects include erythema, pruritus, nausea and headache. While short term adverse effects are limited and reversible after discontinuation of treatment, potential long term adverse effects such as chronic actinic skin damage, dyskeratotic and precancerous skin conditions, nonmelanoma skin cancer, immunological alterations and cataract formation are of greater concern. Long term risks associated with PUVA therapy can be minimised by several measures. Careful patient selection is mandatory; for example, patients with chronic actinic damage and a history of skin cancer may bear a higher risk for the development of new cancers, and previous arsenic intake and ionising radiation also increase the risk of nonmelanoma skin cancers. Certain drug combinations make it possible to lower the UVA dose, which is important because of the dose-dependent increase in the incidence of squamous cell carcinomas in patients treated with PUVA. It has been demonstrated that 200 treatments or a total UVA dose of 1200 J/cm2 seems to be the threshold for development of nonmelanoma skin cancer. Shielding male genitalia during PUVA treatment is essential because of the increased risk of genital squamous cell carcinomas. Yearly dermatological examination to detect skin cancer at an early stage is highly advisable. Sunscreen use, protective clothing and avoidance of sun exposure reduce the uncontrolled dose of solar UV radiation. Other psoralens with a less carcinogenic potential can be used. UVA-opaque sunglasses during the entire period of increased photosensitivity after psoralen ingestion help avoid cataract formation. Assignment to PUVA ought to be based on the risk-benefit ratio for the individual patient and should be limited to those who can be monitored and controlled by informed, competent and conscientious physicians.

Treatment of generalized granuloma annulare – a systematic review

“…PUVA has some risks and side‐effects. Long‐term use may lead to actinic damage localized to treatment areas and an increased risk of cutaneous malignancy …”

PUVA‐gel vs. PUVA‐bath therapy for severe recalcitrant palmoplantar dermatoses

“…Systemic psoralen/UVA photochemotherapy has been shown to be effective in the treatment of palmoplantar dermatoses. However, peroral ingestion of the photosensitizer may induce acute unwanted side effects such as nausea, vomiting, headaches and prolonged sensitivity to UV irradiation with subsequent necessity of intensive UV protection for the whole body (16, 17). Therefore, alternative treatment modalities that limit photosensitization to the affected skin areas only have been developed (7, 12).…”

Report of the Topical Calcineurin Inhibitor Task Force of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology

“…It is important to reinforce the need for adjunctive treatment for AD, including liberal moisturization, evaluation for food and inhalant allergies, treatment of infections, and referral to an allergistimmunologist or a dermatologist for identification of triggers and optimal skin care. Erythema, pruritis, nausea, headache, chronic actinic skin damage, dyskeratotic and precancerous skin conditions 22,25,27,34 UVA, Ultraviolet A; UVB, ultraviolet B; PUVA, psoralen plus ultraviolet A. *Adverse effects relate to corticosteroid potency, occlusiveness of the preparations, site of application, percentage of the body surface covered, and duration of treatment.…”