ARTICLE
Auteur(s) : Jana Trott1, Wolfgang
Gerber1, Stefan Hammes2, Hans-Michael
Ockenfels1
1Department of Dermatology and Allergology, Klinikum
Hanau, Leimenstraße 20, 63450 Hanau, Germany
2Laserklinik, Karlsruhe, Germany
accepté le 2 Août 2007
Phototherapy has been shown to be one of the most effective
treatment methods for inflammatory skin diseases, especially for
patients with psoriasis [1, 2]. Photochemotherapy using
8-methoxypsoralen plus ultraviolet A (PUVA) or narrow-band
ultraviolet B (NUVB) by means of a fluorescent irradiation device
which delivers virtually monochromatic light at 311 nm are
considered to be the principal phototherapies for patients with
moderate to severe psoriasis [3-5]. Bath-PUVA has become an
alternative to oral-PUVA [4, 6]. Statistically, there is no
significant difference between the two when comparing their
efficacy for clearing psoriasis. However, bath-PUVA is more
advantageous as it has less side-effects [6, 7]. In contrast, the
efficacy of NUVB phototherapy and PUVA for chronic plaque psoriasis
is a matter of controversy. Most studies prefer PUVA [1, 8-10] but
recently some researchers have suggested that NUVB could become the
first treatment of choice for moderately severe to severe chronic
plaque psoriasis [1, 11-13]. Unfortunately, both types of therapy
require more than 25 treatment sessions and radiation is given to
the whole skin, including unaffected skin. The cumulative
UV-dosages and the potential risk of skin cancer induction on
unaffected skin by PUVA and NUVB led to phototherapeutic protocols
which used either PUVA or NUVB and not a combination of both
[14-16].
Since 2000 we have been able to apply remedial monochromatic UVB
light (308 nm) directly to affected psoriatic skin using an excimer
laser [17]. This therapy has been shown to be more effective and
safer than conventional NUVB for psoriasis treatment [18-24]. The
laser only targets the affected areas of the skin, sparing the
surrounding skin which is not affected. Less than 12 treatment
sessions are necessary [17-19, 25, 26] and the UVB dosage can be
applied directly to the psoriatic lesions starting with MED-I
dosage [18]. There have been reports that at least 75% clearance of
psoriatic lesions was achieved during an average of 10 sessions
[18, 19, 21, 25, 26]. Although the excimer laser treatment was only
performed on moderate psoriasis with affected skin < 20%, we
were interested in treating severe psoriasis by combining UVB 308
nm excimer radiation and PUVA. The purpose of this study was to
demonstrate the efficacy of combining the two phototherapies and
comparing this combination method with the PUVA-alone method in the
treatment of moderate to severe chronic plaque psoriasis (> 20%
of body surface).
Patients and methods
Patients
An open, prospective, random, parallel group study was undertaken
to analyse whether the combination method of UVB 308-nm excimer
laser radiation and PUVA is more effective than the PUVA-alone
method in the treatment of moderate to severe psoriasis. 272
patients (162 men and 110 women, mean age of 50) with severe
chronic plaque-type psoriasis of variable duration affecting >
20% of the body surface were included in the research undertaken
between January 2002 and December 2004 in the Department of
Dermatology of the Klinikum Hanau, after obtaining their informed
consent. Patients were hospitalized at the start and, after 2-4
weeks, therapy was continued on an out-patient basis. The
randomization was performed with computer-generated random numbers.
Patients fulfilling one or more of the following criteria: systemic
antipsoriatic treatment during the previous 4 months, topical
treatment (e.g. glucocorticosteroids) and other types of light
therapy during the previous 2 weeks, concomitant or previous
malignant skin tumors and aged less than 18 years were excluded
from the study. The patients’ clinical features were quantified at
baseline and at the end of therapy according to the mean psoriasis
area and Psoriasis Severity Index Score (PASI), which assesses the
degree of erythema, infiltration and scaling of psoriatic lesions.
The patients included in the study were of skin types I-IV
according to the working classification of sun-reactive skin-types
(I-VI).
The first group comprised 123 patients (70 men, 53 women; mean
age 49.5 ± 16.3) who received PUVA monotherapy treatment. Psoriasis
Area and Severity index score (PASI) ranged from 12 to 34 (mean
value ± SD: 23.5 ± 6.5). Therapeutic efficacy, number of treatment
sessions and cumulative UV doses up to remission were calculated to
compare the PUVA-alone method with the PUVA and UVB laser
phototherapy combination. The second group with 149 patients (92
men, 57 women; mean age 48.6 ± 14.7) (PASI score of 14-35; mean
value ± SD: 24 ± 6) were treated with PUVA and up to 4 sessions of
308 nm excimer laser during the first two weeks.
PUVA therapy
The UV 7001 K cabinet (Waldmann Medizintechnik) equipped with F
85/100 W-PUVA lamps from Philips (λem = 315-400 nm with
a maximum at 365 nm) was used in this study for UVA irradiation.
Patients received 0.6 mg/kg b.w. 8-methoxypsoralen (8-MOP) orally 2
hours before irradiation. Eyes were protected with special
UVA-block sunglasses which had to be worn for at least 8 hours
after drug intake. Prior to treatment, the minimum phototoxic dose
(MPD) was determined in all patients as described.
Bath-PUVA therapy
We used the identical light as for systemic PUVA. An alcoholic
8-MOP solution (1 g 8-MOP in ethanol 99% ad 1000 mL) was added
to the water, yielding a final concentration of 1 mg 8-MOP/l for
bath PUVA therapy. Patients were then advised to take a whole-body
bath for about 20 min. at 37 °C water temperature. Irradiation
with UVA was performed immediately after the bath.
PUVA strategy
PUVA treatment was given 4 times a week. The initial light dose was
0.4-0.8 J/cm2 depending on skin type and MPD. The UVA
dose was increased by increments of 0.5 J/cm2 after
each second or third treatment according to the response and degree
of erythema caused by the previous exposure. Irradiation was not
increased when a slight erythematous reaction occurred. Treatment
sessions were omitted when a more severe erythematous reaction
occurred (first degree sunburn). Irradiation was given until
complete or almost complete (slight residual infiltration and
erythema) clearance, or over a maximum period of 6 weeks. Therapy
was discontinued when there was no improvement after 6 weeks of
treatment.
Statistically, there was no significant difference between PUVA
and bath-PUVA therapy in either treatment group (group A: 63
patients received PUVA and 60 patients bath-PUVA therapy; group B:
68 patients were treated with PUVA and 81 with bath-PUVA
irradiation).
Excimer 308-nm laser
Stella®, an excimer laser manufactured by TUI Laser AG
(Munich, Germany), generating monochromatic light on the wavelength
308 nm by means of xenon-chloride gas was used in the study. The
area to be treated is illuminated through a 800-μm flexible fibre
delivery system with intensive narrow-band laser radiation of 307.9
± 0.15 nm with a fixed repetition rate of 200 Hz of 400 mW
cm–2 intensity at the square hand-piece treatment area.
Dosages (measured in mJ) were applied to the plaques by a 14 ×
14 mm hand-piece. Treatment commenced with MEDI-I, following a
pre-assessment of the minimum erythema dose on infiltrated
psoriatic skin (MED-I), as previously described (figure 1). Doses of 300,
400 and 500 mJ/cm–2 were administered for skin
phototypes I to III, additionally 600 and 700 mJ/cm2 for
skin type IV to VI. The lowest dosage caused increased erythema of
the affected skin after 24 hours (MED-I) but no blisters were
apparent using this starter dose. All patients in both groups were
also allowed to use emollient ointments as required [18]. As can be
seen in figure
1, it is very easy to distinguish between the psoriatic
plaque and healthy, unaffected skin on account of the redness of
the plaque. This means that UVB laser rays can easily be applied to
the plaque itself using a 2 cm2 hand-piece and the
affected skin alone can be treated using the UVB 308 nm excimer
laser. At the beginning, the dose was not increased at each
treatment session on account of the additional PUVA-therapy and the
related healing and thinning process of psoriatic plaques. Fluence
was only increased in a stepwise manner of
0.2 J/cm2 in the absence of significant redness
from the previous treatment session.
Evaluation of the effectiveness of therapy
Therapy effectiveness was defined as the researcher’s overall
assessment of response to treatment in percentage improvement
compared with the original extent of the disease, i.e. a PASI
reduction of ≥ 90% was defined as complete clearance, a PASI
reduction of ≥ 50% as considerable improvement, and a reduction of
≤ 50% as slight improvement compared to the beginning of treatment.
Using a blinded observer was not practicable because of the visible
difference between the two groups. Clinical improvement and also
irradiation dose, side-effects and reasons for dropout were
documented over a time period of 4 months. At the same time,
photographs were taken before and after treatment. The
post-treatment follow-up period was 3 months. Fewer relapses were
observed in the combination therapy group during this period, but
the difference was not significant (13 versus 18).
Statistical analysis
Results were based on the number of treatments, time in weeks and
the cumulative doses needed to achieve clearence. With regard to
discontinuation of treatment or “drop-outs”. The principal analysis
was by ITT for all end-points. We compared these results and
psoriasis severity scores at baseline and at the end of treatment
for the two groups using the Wilcoxon-Mann-Whitney test. Data was
expressed as mean ± standard deviation of the mean. Probability
values smaller than 5% (p < 0.05) were considered as
significant.
Results
A total of 272 patients with moderate to severe chronic plaque-type
psoriasis and skin types ranging from I to IV were enrolled in this
study. 256 patients (151 men; 105 women; 113 in the first group and
143 in the second group) completed the full therapy protocol.
Sixteen patients (11 men; 5 women) dropped out. The main protocol
deviations occurred in patients who terminated treatment earlier
and who had fewer than five treatment sessions. These patients did
not find enough time for therapy; none terminated treatment because
of side-effects.
Clinical efficacy
PUVA therapy
PUVA used as a monotherapy notably reduced PASI scores in the first
group after an average treatment time of 6.5 weeks in 90.3%
(102/113) of patients. In this study, complete clearance could be
reached in 67.3% (76/113). Partial clearance could be seen in 23%
(26/113) of patients and 9·7% (11/113) were non-responders who
showed a slight improvement of less than 50%. The main cumulative
UVA dose was 53.2 J/cm2 ± 26.3 J/cm2 (range
14·4 J/cm2-156.5 J/cm2) and the mean number
of treatment sessions was 26 ± 7.
Combination Phototherapy: PUVA plus UVB versus excimer
laser
When focusing on the 149 patients treated with the combination
phototherapy, complete clearance was observed in 63.6% (91/143) of
patients, a partial improvement occurred in 28% (40/143) and 8.4%
(12/143) showed no response during therapy (figure 2). There was no
significant difference regarding the efficacy of treatment when the
results of the different phototherapeutic models (UVA vs UVA plus
UVB) were compared (p > 0.05). However, the number of treatment
sessions needed to achieve clearance in the combination
phototherapy group was much lower (15 ± 6; p < 0.05) and the
cumulative UVA dose decreased to 22.9 J/cm2 ± 5.8
J/cm2 (range 8.3 J/cm2-98.9 J/cm2;
p < 0.01). The average time was 4.2 weeks. The number of
additional excimer laser treatments applied was 2.8 ± 0.9 with a
UVB dose of 1.872 ± 1.492 mJ. No side-effects other than moderate
erythema, hyperpigmentation and blistering as a result of MED-I
testing were observed. The demographic data of these patients and
their response to therapy are summarized in tables 1 and 2.
Table 1 Demographic data, PASI score at baseline and
results of UV therapy of patients with moderate to severe
plaque-type psoriasis
|
Photo therapy
|
Number of patients
|
Sex
|
Age, years
|
PASI at baseline
|
Complete clearance
|
Partial clearance
|
Slight improvement
|
|
|
|
m
|
f
|
mean ± SD
|
mean ± SD
|
(≥ 90%)
|
(≥ 50%)
|
(≤ 50%)
|
|
PUVA
|
123
|
70
|
53
|
49.5 ± 16.3
|
23.5 ± 6.5
|
67.3%
|
23.0%
|
9.7%
|
|
PUVA + excimer
|
149
|
92
|
57
|
48.6 ± 14.7
|
24.0 ± 6.0
|
63.6%
|
28.0%
|
8.4%
|
|
Total
|
272
|
162
|
110
|
49.05 ± 15.5
|
23.75 ± 6.25
|
65.45%
|
25.5%
|
9.05%
|
Table 2 Treatment results
|
Phototherapy
|
Cumulative UVA dose (J/cm2)
|
Cumulative UVB dose (mJ)
|
Number of the UVA application
|
Number of the UVB application
|
Drop-outs
|
|
mean ± SD
|
mean ± SD
|
mean ± SD
|
mean ± SD
|
(of treated patients)
|
|
PUVA
|
53.2 ± 26.3
|
-
|
27 ± 7
|
-
|
7
|
|
PUVA + excimer
|
22.9 ± 5.8
|
1872 ± 492
|
15 ± 6
|
2.8 ± 0.9
|
9
|
|
Total
|
39.75 ± 16.05
|
1872 ± 492
|
21 ± 6.5
|
2.8 ± 0.9
|
|
Discussion
Systemic PUVA therapy, bath-PUVA therapy and UVB therapy,
especially narrow-band UVB (NUVB) are routinely used in the
treatment of moderate to severe chronic psoriasis [1, 2, 28].
However, deciding which of these therapies is the most suitable for
each individual patient is often difficult. A comparison of studies
shows varying results with some studies tending to favour PUVA over
NUVB therapy or vice-versa [8-13]. However, the purpose of this
study was not to show that one UV monotherapy was better than
another, using yet another monotherapy design and a systematic
review of UVA- and UVB-phototherapies. The main question was
whether, by developing sources of laser therapy further,
specifically the UVB 308 nm using an excimer laser which is applied
directly to the plaque, it is possible to combine monotherapeutic
UVB therapy, which is available nowadays and is extremely
effective, with a whole body PUVA treatment. In both branches of
the study we treated a total of 256 people with bath or systemic
PUVA. There were no significant differences regarding the number of
treatment sessions for lesions to clear completely and the
clearance rate, the number of treatment sessions and the cumulative
doses were comparable to studies published earlier [1, 9, 27]. In
his systematic review, Spuls, for example, achieved a 70% clearance
rate of severe psoriasis using PUVA and he reported an improvement
of 75%-100% in 83% of the cases. The tolerance level of PUVA
therapy is good and the dropout rate is less than 9%. Less than 2%
of dropouts discontinue therapy as a result of redness or burning
[5].
8.8% of the PUVA monotherapy group and 4.1% of the PUVA+UVB
group discontinued therapy prematurely, not because of side effects
but because of lack of time. In this respect, our experience has
shown that the number of patients who discontinue therapy in the
UVB combination group and the PUVA group are, statistically, no
less than those who discontinue excimer laser therapy: Although, in
individual cases, some blisters can form in the plaque despite
using MEDI, this is not a reason for these patients to discontinue
therapy and is not seen to restrict the quality of life. However,
it is important to avoid carrying out aggressive laser therapies
without the use of MEDI or an adjusted dose, as practised by other
authors. The results of the PUVA group are also representative with
regard to the cumulative UVA dose. The majority of studies,
particularly those with a large number of patients, show the
cumulative doses required to be around 65 ± 40 J/cm2 [1,
9]. We needed 53.2 + 26.3 J/cm2 in the PUVA group with
an average of 27 ± 7 treatments. Patients in the second group who
received at most an extra four laser therapy sessions using 308 nm
UVB applied directly to the affected skin, only required an average
of 15 ± 6 PUVA treatment sessions and the cumulative UVA dose was
reduced dramatically by more than 50% to 22.9 + 5.8 J. Even the few
studies undertaken on a small number of patients required PUVA
doses of 34-37 J/cm2 [6, 27, 29] to heal the psoriasis
after less than 20 PUVA sessions. Collins was able to show that
high cumulative PUVA doses (> 60 J/cm2), which
constantly take MPD into consideration and not the skin type, are
necessary to achieve a long period of remission of at least 42%
[30].
There were also several benefits to the patient when treated
with the combination therapy: i) the patient needed an average of
12 treatment sessions less than traditional oral or bath- PUVA
therapy. Many patients, particularly those with a long distance to
travel, are not able to visit their dermatologist 25 times or more.
A therapy concept requiring less UV radiation treatment sessions
with the same success rate will become generally accepted for both
out-patients and patients requiring a hospital stay. ii) It is
indisputable that there is an increased frequency of patients
developing skin cancer when they receive oral PUVA therapy
frequently over many years [31, 32]. Therefore, theoretically,
there is less cancerogenic risk if the cumulative PUVA dose is
reduced and the clearance rate remains the same, especially if PUVA
therapy is repeated over many years. Compared to oral PUVA therapy,
there should be a much smaller risk of developing skin cancer using
UVB therapy [14, 15, 33, 34]. However, we would like to emphasize
that this consideration is analytical on account of the measured
cumulative doses and would need to be confirmed in a long-term
study over the next few years. Unlike traditional UVB or NUVB
therapy, an additional UVB 308 nm dose of 4 ± 3 J is required, a
far smaller dose than that used in traditional NUVB therapy.
Depending on the study design, the cumulative doses used in
traditional therapy fluctuate between 17-30 J/cm2
[11-13, 18, 35]. As is the case when using a 308 nm excimer laser,
only the affected areas of skin are treated with the individual
dose, which depend on the MED-I start dose and all the healthy skin
is excluded.
Together with other groups, we first used the laser to treat
psoriasis when the disease was confined to less than 10% TBSA and
showed that more than 80% of enrolled patients experienced more
than 75% clearance after 10 treatment sessions with the excimer
laser [17, 18]. Plaque thickness often varies among patients. Very
thick plaques can be found on the “problem zones” of the elbow,
knee, sacral regions etc. and are often resistant to general PUVA
or UVB therapy [36]. In contrast to other groups [21, 22], whose
treatment is a multiple MED-dose, we are able to tailor the exact
dosage for the plaque thickness by determining the MEDI [18].
Taibjee, therefore, also calls our MED-I determination, the
“response-based-method” [37].
It is very time-consuming to give additional laser treatment to
a patient with moderate-severe psoriasis using the UVB 308 excimer
laser. The time needed for a back (figure 2) is about 20
minutes and the extra material strain on the excimer tubes must
also be taken into consideration. These arguments stand in the way
of treating patients with large areas of chronic psoriasis using
308 nm excimer laser therapy applied directly to the plaque. The
advantages of using UVB therapy directly on the affected skin are
huge compared to a non-specific traditional UVB therapy which is
not tailored to each individual plaque. In this way, excimer laser
therapy has already successfully been used on vitiligo, mycosis
fungoides and alopecia areata [23, 24, 26, 40-42]. In the same way
as psoriasis, all these diseases are dependent on the T cell.
Bianchi et al. describe a depletion of T cells 48 hours after the
first irradiation using UVB 308 nm directly on the psoriatic plaque
[43]. T cells are eliminated from the psoriatic epidermis as well
as from the dermis, suggesting the enhanced ability of this UVB
radiation to penetrate the skin in comparison to normal UVB and to
establish direct cytotoxic action of T cells infiltrating skin
lesions. Furthermore, alterations of apoptosis-related molecules
accompanied by a decreased proliferation index of keratinocytes
could be observed after 308 nm therapy. These cellular mechanisms
explain the laser therapy studies developed earlier which recommend
direct laser therapy only twice a week [17, 21, 43, 44].
PUVA is similar to UVB in that it causes apoptosis of T cells,
whereby the major long-term adverse effect of photochemotherapy to
develop photoaging and cutaneous malignancies seems to be higher
for oral PUVA therapy than for UVB phototherapy [4, 8, 16, 33, 35].
The putative cumulative adverse effects and the lack of special
laser equipment were the reasons for not being able to combine both
UV-light therapies (NUVB and PUVA) to date. Ortel (1993) and Arnold
(2001) combined an 8-methoxypsoralen bath with NUVB but were
unsuccessful [38, 39].
It is only because of modern laser technology that a synergy
effect of (308 nm) combined with PUVA is possible. The maximum
synergy effect can, therefore, be interpreted as the use of the
excimer laser derived UVB 308 nm therapy with the dose applied
directly to the plaque and PUVA.
The light absorption spectrum for oral psoralen peaks between
325–335 nm. PUVA treatment using 335-nm UVA is twice as effective
as with 365-nm UVA with respect to both erythemogenicity and the
cumulative dose required for clearing psoriasis; however, 335-nm
and 365-nm are equally effective if delivered in equal erythema
doses, suggesting that in human skin the antipsoriatic activity of
8-MOP parallels its erythemogenicity [3, 38, 39]. Because the
excimer laser derived UVB is fully monochromatic at 308 nm, this
pure light shows no additioned erythemogenicity to the PUVA
pretreatment. Patients were lasered 4 – 6 hours after the PUVA bath
and also 4-6 hours after the intake of psoralen, and there were no
differences seen in the reaction of laser treated skin between the
two groups.
Amazingly, however, the clearance rate did not improve. Perhaps
the reason was because in many protocols, PUVA therapy results in a
higher clearance rate of approx. 85% compared to 70% using NUVB
therapy [1, 4-6, 9, 27]. Therefore, it could be claimed that the
PUVA non-responder could also be a NUVB non-responder.
In addition, it was not the aim of this study to increase the
PUVA responder. After all, the plaques were only treated with 308
nm UVB an extra 4 times, and not 10 times as a curative measure. In
addition to PUVA, the standard excimer protocol would have to be
taken into account before making statements about the clearance
rate [18].
Nonetheless, we are of the opinion that UVA and NUVB should only
be applied to chronic dermatoses such as psoriasis with as much
care as possible. We recommend laser therapy in the treatment of
chronic or localised psoriasis using 308 nm excimer UVB which is
applied directly to the plaque, the use of which has been described
over the last few years, and even more recently in a pilot study on
the therapy of children [19]. The severe plaque types of psoriasis,
where laser therapy can be used, can be very well treated by using
as small a dose as possible and in the least amount of time,
combined with oral or bath- PUVA, supported by a few UVB excimer
irradiations which are applied directly to the plaque.
The aim of laser therapy in chronic dermatosis has to be a
reduction in the side-effects such as photoaging and the
cancerogenic risk, by lowering cumulative doses. Only a few 308-nm
UVB treatment sessions, leading to low cumulative doses of PUVA,
are required to achieve clearance when the combination therapy is
used.
Acknowledgements
Financial support: none. Conflict of interest: none.
References
1 Karrer S, Eholzer C, Ackermann G,
Landthaler M, Szeimies RM. Phototherapy of psoriasis:
Comparative experience of different phototherapeutic approaches.
Dermatology 2001; 202: 108-15.
2 Hönigsmann H, Szelmis RM, Knobler R,
Fitzpatrick TB, Pathak MA, Wolff K.
Photochemotherapy and photodynamic therapy. In: Freedberg IM,
Eisen AZ, Wolff K, et al., eds. Fitzpatrick’s
dermatology in general medicine. New York: McGraw-Hill, 1999:
2880-900.
3 Henseler T, Wolff K, Hönigsmann H,
Christophers E. Oral 8-methoxypsoralen photochemotherapy of
psoriasis. The European PUVA study: a cooperative study among 18
European centres. Lancet 1981; 8225: 853-7.
4 Gasparro FP. The role of PUVA in the treatment of
psoriasis. Am J Clin Dermatol 2000; 1(6): 337-48.
5 Spuls PI, Witkamp L, Bossuyt PMM, Bos JD.
A systematic review of five systemic treatments for severe
psoriasis. Br J Dermatol 1997; 137: 943-9.
6 Cooper EJ, Herd RM, Priestley GC,
Hunter JAA. A comparison of bathwater and oral delivery of
8-methoxypsoralen in PUVA therapy for plaque psoriasis. Clin Exp
Dermatol 2000; 25: 111-4.
7 Lüftl M, Degitz K, Plewig G, Röcken M.
Psoralen bath plus UV-A therapy. Possibilities and limitations.
Arch Dermatol 1997; 133: 1597-603.
8 Coven TR, Walters IB, Cardinale I,
Krueger JG. PUVA-induced lymphocyte apoptosis: Mechanism of
action in psoriasis. Photodermatol Photoimmunol Photomed 1999; 15:
22-7.
9 Gordon PM, Diffey BL, Matthews JNS,
Farr PM. A randomized comparison of narrow-band TL-01
phototherapy and PUVA photochemotherapy for psoriasis. J Am Acad
Dermatol 1999; 41(5): 728-32.
10 Van Weelden H, Baart de la Faille H, Young E,
van der Leun JC. Comparison of narrow-band UV-B phototherapy
and PUVA photochemotherapy in the treatment of psoriasis. Acta Derm
Venereol 1990; 70: 212-5.
11 Dawe RS, Cameron H, Yule S, Man I,
Wainwright NJ, Ibbotson SH, Ferguson J. A randomized
controlled trial of narrowband ultraviolet B vs bath-psoralen plus
ultraviolet A photochemotherapy for psoriasis. Br J Dermatol 2003;
148(6): 1194-204.
12 Walters IB, Burack LH, Coven TR,
Gilleaudeau P, Krueger JG. Suberythemogenic narrow-band
UVB is markedly more effective than conventional UVB in the
treatment of psoriasis vulgaris. J Am Acad Dermatol 1999; 40(6):
893-900.
13 Wainwright NJ, Dawe RS, Ferguson J.
Narrow-band ultraviolet B (TL-01) phototherapy for psoriasis: which
incremental regimen? Br J Dermatol 1998; 139: 410-4.
14 Stern RS, Nichols KT, Vakeva LH. Malignant
melanoma in patients treated for psoriasis with methoxsalen
(psoralen) and ultraviolet A radiation (PUVA): the PUVA follow-up
study. N Engl J Med 1997; 336: 1041-5.
15 Stern RS, Lunder EJ. Risk of squamous cell
carcinoma and methoxsalen (psoralen) and UV-A radiation (PUVA): a
meta-analysis. Arch Dermatol 1998; 134: 1582-5.
16 Krutmann J. Photocarcinogenesis. Schweiz Rundsch Med
Prax 2001; 90(8): 297-9.
17 Asawanonda P, Anderson RR, Chang Y,
Taylor CY. 308-nm excimer laser for the treatment of
psoriasis: a dose response study. Arch Dermatol 2000; 136:
619-24.
18 Gerber W, Arheilger B, Ha TA, Hermann J,
Ockenfels HM. Ultraviolet B 308-nm excimer laser treatment of
psoriasis: a new phototherapeutic approach. Br J Dermatol 2003;
149: 1250-8.
19 Pahlajani N, Katz BJ, Lozano AM,
Murphy F, Gottlieb A. Comparison of the efficacy and
safety of the 308-nm excimer laser for the treatment of localized
psoriasis in adults and in children: a pilot study. Pediatr
Dermatol 2005; 22(2): 161-5.
20 Taneja A, Trehan M, Taylor CR. 308-nm excimer
laser for the treatment of psoriasis. Arch Dermatol 2003; 139:
759-64.
21 Salam Housman T, Pearce DJ, Feldman SR. A
maintenance protocol for psoriasis plaques cleared by the 308-nm
excimer laser. J Dermatol Treatment 2004; 15: 94-7.
22 Trehan M, Taylor CR. Medium-dose 308-nm excimer
laser for the treatment of psoriasis. J Am Acad Dermatol 2002;
47(5): 701-8.
23 Aubin F, Vigan M, Puzenat E, Blanc D,
Drobacheff P, Deprez P, Humbert P, Laurent R.
Evaluation of novel 308-nm monochromatic excimer light delivery
system in dermatology: a pilot study in different chronic localized
dermatoses. Br J Dermatol 2005; 152: 99-103.
24 Passeron T, Zakaria W, Ostovari N,
Perrin C, Larrouy JC, Lacour JP, Ortonne JP.
Efficacy of the 308-nm excimer laser in the treatment of mycosis
fungoides. Arch Dermatol 2004; 140: 1291-3.
25 Novak Z, Bonis B, Baltas E, et al. Xenon
chloride ultraviolet B laser is more effective in treating
psoriasis and in inducing T cell apoptosis than narrow-band
ultraviolet B. J Photochem Photobiol 2002; 67: 32-8.
26 Raulin C, Grema H. Psoriasis vulgaris. Indikation
für den Laser? Hautarzt 2003; 54: 242-7.
27 Tzaneva S, Seeber A, Hönigsmann H,
Tanew A. A comparison of psoralen plus ultraviolet A (PUVA)
monotherapy, tacalcitol plus PUVA and tazarotene plus PUVA in
patients with chronic plaque-type psoriasis. Br J Dermatol 2002;
147: 748-53.
28 Pasker-de Jong CM, Wielink G, van der Valk GM,
van der Wilt GJ. Treatment with UV-B for psoriasis and
nonmelanoma skin cancer. Arch Dermatol 1999; 135: 834-40.
29 Grundmann-Kollmann M, Tegeder I,
Ochsendorf FR, Zollner TM, Ludwig R,
Kaufmann R, et al. Kinetics and dose-response of
photosensitivity in cream psoralen plus ultraviolet A
photochemotherapy: comparative in vivo studies after topical
application of three standard preparations. Br J Dermatol 2001;
144: 991-5.
30 Collins P, Wainwright NJ, Amorim I,
Lakshmipathi T, Ferguson J. 8-MOP PUVA for psoriasis: a
comparison of a minimal phototoxic dose-based regimen with a
skin-type approach. Br J Dermatol 1996; 135: 248-54.
31 Lindelöf B, Sigurgeirsson B, Tegner E,
Larkö O, Johannesen A, Berne B, et al. PUVA and
cancer risk: the Swedish follow-up study. Br J Dermatol 1999; 141:
108-12.
32 Hannuksela A, Pukkala E, Hannuksela M,
Karvonen J. Cancer incidence among Finnish patients with
psoriasis treated with trioxsalen bath PUVA. J Am Acad Dermatol
1996; 35: 685-9.
33 Krutmann J, Morita A. Mechanisms of ultraviolet
(UV) B and UVA phototherapy. J Investig Dermatol Symp Proc 1999;
4(1): 70-2.
34 Stern RS, Laird N. The carcinogenic risk of
treatment for severe psoriasis. Cancer 1994; 73: 2759-64.
35 el-Ghorr AA, Norval M. Biological effects of
narrow-band (311 nm TL01) UVB irradiation: A review. J Photochem
Photobiol 1997; 38(2,3): 99-106.
36 Coven TR, Burack LH, Gilleaudeau R,
Keogh M, Ozawa M, Krueger JG. Narrow-band UV-B
produces superior clinical and histopathological resolution of
moderate-to severe psoriasis in patients compared with broadband
UV-B. Arch Dermatol 1997; 133: 1514-22.
37 Tajbjee SM, Cheung ST, Laube S,
Lanigan SW. Controlled study of excimer and pulsed dye lasers
in the treatment of psoriasis. Br J Dermatol 2005; 153: 960-6.
38 Ortel B, Perl S, Kinaciyan T, et al.
Comparison of narrow-band (311 nm) UVB and broad-band UVA after
oral or bath-water 8-MOP in the treatment of psoriasis. J Am Acad
Dermatol 1993; 29: 736-40.
39 Arnold WP, van Andel P, de Hoop D, de
Jong-Tieben L, Visser-van Andel M. A comparison of the
effect of narrow-band ultraviolet B in the treatment of psoriasis
after salt-water baths and after 8-methoxypsoralen baths. Br J
Dermatol 2001; 145: 352-542.
40 Alexiades-Armenakas MR, Bernstein LJ,
Friedman PM, Geronemus RG. The safety and efficacy of the
308-nm excimer laser for pigment correction of hypopigmented scars
and striae alba. Arch Dermatol 2004; 140: 955-60.
41 Hofer A, Hassan AS, Legat FJ, Kerl H,
Wolf P. Optimal weekly frequency of 308-nm excimer laser
treatment in vitiligo patients. Br J Dermatol 2005; 152: 981-5.
42 Gupta SN, Taylor CR. 308-nm excimer laser for the
treatment of scalp psoriasis. Arch Dermatol 2004; 140: 518-20.
43 Bianchi B, Campolmi P, Mavilia L,
Danesi A, Rossi R, Cappugi P. Monochromatic excimer
light (308 nm): an immunohistochemical study of cutaneous T cells
apoptosis-related molecules in psoriasis. J Eur Acad Dermatol
Venereol 2003; 17: 408-13.
44 Ozawa M, Ferenczi K, Kikuchi T,
Cardinale I, Austin LM, Coven TR, Burack LH,
Krueger JG. 312-nanometer ultraviolet B light (narrow-band
UVB) induces apoptosis of T cells within psoriatic lesions. Lab
Invest Dermatol 1999; 189: 711-8.
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