Topical PUVA, Etretinate, and Combined PUVA and Etretinate for Palmoplantar Pustulosis: Comparison of Therapeutic Efficacy and the Influences of Tonsillar and Dental Focal Infections

Abstract

Twenty patients with palmoplantar pustulosis (PPP) were treated with topical PUVA, oral etretinate (Re), or combined PUVA and etretinate (Re-PUVA). Re and Re-PUVA treated sites improved and/or cleared more rapidly than PUVA treated sites. Complete clearance was observed in six of ten sites treated with Re-PUVA, two of ten with Re, and one of ten sites with PUVA within 12 weeks. UVA-control sites failed to be cleared within 12 weeks. Remission periods after stopping the treatment were 1.5 +/- 0.5 weeks (n = 2) with Re, 10.5 +/- 11.4 weeks (n = 6) with Re-PUVA, and one year (n = 1) with PUVA. These results overall suggested that Re-PUVA is the most effective treatment for PPP. Tonsillar focal infection (TFI) and dental focal infection (DFI) were found in 6/20 and 17/20 patients, respectively. However, the presence of focal infection (FI), TFI and/or DFI, did not appear to interfere with the therapeutic activities of Re and/or PUVA, because the complete clearance rates and remission periods in FI(+) patients were comparable with those in FI(-) patients.

Efficacy of topical PUVA soaks for palmoplantar dermatoses: an audit

“…Although UV treatment is often used as a step between topical therapy and oral therapy in the treatment of dermatoses, the threshold for using oral treatment, or oral and PUVA combinations, in palmoplantar pustulosis should be lower than with other dermatoses. Indeed, comparisons between topical PUVA, oral etretinate, and combined etretinate and PUVA (RePUVA) found that Re and RePUVA treated sites cleared more rapidly than PUVA on its own (14).…”

British Association of Dermatologists and British Photodermatology Group guidelines for the safe and effective use of psoralen–ultraviolet A therapy 2015

“…173 The study detected no difference in improvement with topical PUVA compared with placebo. The lack of efficacy of topical PUVA was further supported by smaller randomized studies (10 and five patients, respectively), 156,174 with clearance rates of only 0-10%.…”

“…A further RCT comparing oral PUVA–etretinate vs. oral PUVA alone showed clearance in 100% (8/8) and 44% (four of nine) of patients, respectively . An RCT using 8‐MOP PUVA lotion found 60% (six of 10) of patients clearing with topical PUVA–etretinate compared with 10% (one of 10) receiving topical PUVA alone …”

“…181 An RCT using 8-MOP PUVA lotion found 60% (six of 10) of patients clearing with topical PUVA-etretinate compared with 10% (one of 10) receiving topical PUVA alone. 174 A Cochrane review of the interventions for palmoplantar pustulosis concluded there was evidence for an increased efficacy of retinoids combined with PUVA compared with PUVA used alone. 176 Recommendation (strength of recommendation 1+; level of evidence A) Unless there are contraindications, the combination of oral PUVA with oral retinoids should be considered as a treatment for palmoplantar pustulosis.…”

Evidence‐based recommendations on conventional systemic treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists

“…In palmoplantar pustulosis, five RCT evaluated retinoids as monotherapy, all including etretinate and one comparing etretinate and acitretin. [56][57][58][59][60] In addition, there were three RCT [61][62][63] and two open label studies 64,65 studying the effect of retinoids combined with psoralen plus ultraviolet A (PUVA) therapy. Retinoids were shown to improve palmoplantar pustulosis at a dose of 1 mg ⁄ kg ⁄ day.…”