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Oral isotretinoin followed by psoralens and ultraviolet A or ultraviolet B for psoriasis
Volume 13 Number 1 July, 1985
Correspondence
We dermatologists need to critically examine this issue of undressing patients and the interrelated issue of our responsibility in regard to finding lesions unsuspected by the patient and unrelated to the presenting complaint. I believe this problem should be examined by one of the task forces of the American Academy of Dermatology. Ernst Epstein, M.D. 100 South Ellsworth Ave.', Suite 707 San Mateo, CA 94401
Reply To the Editor: Dr. Kaminester's letter is timely in view of the American Academy of Dermatology's National Melanoma/ Skin Cancer Screening Program this year. I applaud his determined and obviously successful effort to give each of his new patients the optimum of dermatologic expertise by doing a complete skin examination at the first visit. The American Academy of Dermatology (AAD) recommends a complete skin examination annually. The AAD and the American Cancer Society are publishing a skin self-examination technic for malignant melanoma. The technic, developed by AAD members Alfred W. Kopf, M.D., Robert J. Friedman, M.D., and Darrel S. Rigel, M.D., will appear in the May/June 1985, issue of Ca: A Cancer Journal for Clinicians, a publication of the American Cancer Society. The method of introducing the complete skin examination will vary from physician to physician. Some dermatologists may find Dr. Kaminester's "Dear Patient" letter convenient while others may prefer a less structured method. If patients decline the complete examination, they could be invited to be prepared to spend a few extra minutes for the examination at their next visit. The American dermatologists may take advantage of the annual complete skin examination to teach their patients the technic for skin self-examination. Skin examinations by the patient at regular intervals and annual examinations by the dermatologist should result in an informed population, alert to the earliest signs of cancer and melanoma. With early detection and treatment, the prospects for preventing death from melanoma and skin cancer are excellent. Faye D. Arundell, M.D. 825 Oak Grove Ave., Suite D101 Menlo Park, CA 94025
153
Oral isotretinoin followed by psoralens and ultraviolet A or ultraviolet B for psoriasis To the Editor: Systemic retinoid therapy has been used in the past decade for the treatment of psoriasis, acne, ichthyosis, and other disorders of keratinization. 1·4 For psoriasis, the most effective compound has been the aromatic retinoid etretinate (Tegison, USA; Tigason, Europe),s and since the late 1970s investigators have attempted to minimize the dose by combining it with other therapeutic modalities. Clearing of psoriasis is enhanced when etretinate is combined with psoralens and ultraviolet A (PUVA)6'8 or ultraviolet B (DVB).9 Recently, chemically related isotretinoin has been shown to enhance the responsiveness of psoriasis to PUVA. IO We studied isotretinoin followed by DVB or PUVA for the treatment of psoriasis to determine if this would minimize duration of therapy as well as ultraviolet exposure. Methods. Our randomized prospective study involved groups of psoriatic patients who had discontinued all therapy for 2 weeks. Based on clinician's judgment, patients were placed in group A (UVB 5 to 7 times per week), group B (PUVA 3 times per week), or group C (UVB 3 times per week). Patients then randomly received isotretinoin or no therapy prior to UV therapy. Isotretinoin was discontinued after 4 weeks, at which time UVB or PUVA was initiated. Therapy was continued until clearing. A total of sixty-eight patients were entered into the study. Patients in group A generally required hospitalization while those in group C were outpatients. The dosage of isotretinoin in all groups was approximately 1 to 2 rng/kg/day, generally resulting in a dose of 40 mg twice daily. DVB therapy was individualized based on the patient's skin type and response to therapy. PUVA patients, group B, were outpatients treated three times weekly. All PUVA patients were given 8-methoxypsoralen (30-60 mg) 2 hours prior to administration of UVA. All patients were studied to clearing unless they failed therapy. Results. Results for all groups are summarized in Table I. Patients in group Al required an average of 286 minutes of UVB therapy compared with 366 minutes of DVB for those in group A2. Although a trend was evident, this difference is not significant (based on Student's t test; p < 0.05). In group Cl, the total minutes of DVB to clearing was 323, while in group C2, 407 minutes of DVB were required. This difference was not statistically significant (p < 0.05). Patients in group B1 also showed no statistically significant decrease in total UVA exposure compared with those in group B2. Total UVA dose in group Bl averaged 195 joules/cm~ with an average of 17.4 treatments. Total UVA dose in group B2averaged 185
154
Journal of the American Academy of Dermatology
Correspondence
Table I. Summary results of patient that cleared Group
Al (n A2 (n
= 6) = 7)
Bl (n = 10) B2 (n = 9) Cl (n C2 (n
= 6) = 9)
Average % body involved
Average No. of
64 66
30.7 25.8 NS (p < 0.05) 17.4 16.5 NS (p < 0.05) 40.8 36.6 NS (p < 0.05)
55 47 30 36
Rx
Average total UVA (joules/em')
Average total UVB (min)
286 366 NS (p < 0.05) 195 185 NS (p < 0.05) 323 407 NS (p < 0.05)
NS: Not significant. Group A (UVB 5 to 7 times weekly); group B (PUVA); group C (UVB 2 to 3 times weekly). Subgroup 1 (isotretinoin); subgroup 2 (control).
joules/cm2 with an average of 16.5 treatments. Some patients in each of the three groups treated with isotretinoin seemed to show dramatic improvement; however, others became worse, producing a wide range of total ultraviolet light (UVL) required to clear. One patient suffered a significant flare on isotretinoin and dropped out, suggesting that any tendency to improvement on the drug may result from a skewed treatment group. Four patients had significant elevation of serum triglyceride and cholesterol levels and required discontinuation of the isotretinoin. The other expected side effects, including dryness and epistaxis from isotretinoin, were seen in all patients receiving the drug. Discussion. The advantages of combination therapy are readily apparent. One concern of UVL therapy is the increased risk of skin carcinoma, so a reduction of UVL exposure in psoriatics would be beneficial. In addition, isotretinoin is associated with bony abnormalities like hyperostosis II and premature epiphyseal closure1 2 with chronic administration. Since psoriasis is not a curable disease and repeated exposures to these therapies can be expected, a decreased cumulative dose or duration of therapy can only be helpful. The effects of retinoids have not been clearly delineated. The obvious side effects show clinically apparent skin changes. Studies of skin fragility show that retinoids cause fraying or loss of stratum corneum and outer epidermis as well as a loss of desmosomes and tonofilaments. 13 Studies on the effect of isotretinoin on cultured keratinocytes have shown that it retards colony fonnation and increases cell shedding. 14 These cells are less stratified with fewer cell layers and are less differentiated. 15 Most patients in groups AI, Bl, and Cl had little
or no response to isotretinoin alone, and some actually flared. One patient with severe psoriasis did have a dramatic improvement in response to isotretinoin alone. He then flared when PUVA was begun and subsequently was maintained just on isotretinoin. Two patients in group B failed PUVA alone after 3 months. Later they were pretreated with isotretinoin, off protocol, prior to PUVA, both completely clearing. Honigsmann and Wolff1o reported sixty patients with severe psoriasis randomly assigned to groups receiving isotretinoin or etretinate followed by PUVA. Both retinoids were administered orally at daily doses of 1.0 mg/kg for 5 days before PUVA therapy was started. Retinoid therapy continued until psoriasis had cleared completely, at which time the retinoids were discontinued and patients were put on PUVA maintenance therapy. They found no difference between groups (isotretinoin/PUVA vs etretinate/PUVA) when comparing duration of therapy, number of treatments to clearing, and total dose (joules/cm2). There was a significant difference when compared to previous reports of PUVA alone. Others l6 have shown no augmentation of response of psoriasis to PUVA by etretinate. Our results do not support pretreatment of isotretinoin prior to PUVA or UVB in the treatment of psoriasis. Other studies have found a synergistic effect when using isotretinoin or etretinate in combination with PUVA or UVB. Although there was improvement in isolated cases, it seems more likely that the effects of isotretinoin are reversible and do not last through an entire course of UVL. Isotretinoin will affect psoriasis, but improvement of the disease is not significant for most patients unless concomitantly augmented with UVB or PUVA. This would most likely minimize long-
Volume 13 Number 1 July, 1985
tenn effects of both therapies and should be considered in cases of recalcitrant disease.
Randall K. Roenigk, MD. Department of Dermatology University of Minnesota, Minneapolis, MN 55455 Connie Gibstine, M.D., and Henry H. Roenigk, Jr., MD. Department of Dermatology Northwestern University Medical School Chicago, IL 60611 REFERENCES 1. Goldsmith LA, Weinrich AE, Shupack J: Pityriasis rubra pHaris response to 13-cis-retinoic acid (isotretinoin). J AM ACAD DERMATOL 6:710-715, 1982. 2. Baden HP, Buxman MM, Weinstein GD, Yoder FW: Treatment of ichthyosis with isotretinoin. J AM ACAD DERMATOL 6:716-720, 1982. 3. Dicken CH, Bauer EA, Hazen PG, et al: Isotretinoin treatment of Darier's disease. J AM ACAD DERMATOL 6:721-726, 1982. 4. Bergfeld WF, Derbes VJ, Elias PM, et al: The treatment of keratosis palmaris et plantaris with isotretinoin. J AM ACAD DERMATOL 6:727-731, 1982. 5. Ehmann CW, Voorhees JJ: International studies of the efficacy of etretinate in the treatment of psoriasis. J AM ACAD DERMATOL 6:692-696, 1982. 6. Grupper C, Berretti B: Treatment of psoriasis by oral PUVA therapy combination aromatic retinoid (re-PUVA), in Orfanos CE, Braun-Falco 0, Farber EN, et ai, editors: Retinoids-advances in basic research and therapy. Berlin, 1981, Springer-Verlag, pp. 341-345. 7. Lauranta J, Juvakoski T, Kaneruva L, Lassus A: Aromatic retinoid (Ro 10-9359), re-PUVA and PUVA in the treatment of psoriasis, in Orfanos CE, Braun-Falco 0, Farber EM, et ai, editors: Retinoids-advances in basic research and therapy. Berlin, 1981, Springer-Verlag, pp. 201-205. 8. Wolff K, Fritsch PO: Retinoid-PUVA chemo-photochemotherapy, in Farber EM, Cox AJ, editors: Psoriasis: Proceedings of the Third International Symposium, 1981. New York, 1982, Grune & Stratton, Inc., pp. 211-219. 9. Boer J, Suurmond D: Combined UVB phototherapy and low dose oral retinoid Ro 10-9359 for psoriasis responding inadequately to DVB alone, in Orfanos CE, BraunFalco 0, Farber EM, et ai, editors: Retinoids-advances in basic research and therapy. Berlin, 1981, SpringerVerlag, pp. 439-442. 10. Honigsmann H, Wolff K: Isotretinoin-PUVA for psoriasis. Lancet 1:236, 1983. (Letter to Editor.) 11. Pittsley RA, Yoder FW: Skeletal toxicity associated with long-term administration of 13-cis-retinoic acid for refractory ichthyosis. N EnglJ Med 308: 1012-1014, 1983. 12. MHstone LM, McGuire J, Ablow RC: Premature epiphyseal closure in a child receiving oral 13-cis-retinoic acid. J AM ACAD DERMATOL 7:663-666, 1982. 13. Williams ML, Elias PM: Nature of skin fragility in patients receiving retinoids for systemic effect. Arch Dermatol117:611-619, 1981.
Correspondence 155
14. McGuire J, Fedarko N, Johanssen E, et al: The influence of retinoids on cultivated human keratinocytes. J AM ACAD DERMATOL 6:630-639, 1982. 15. Kubilus J: Modulation of differentiation by retinoids. J Invest Dermatol 81:555-585, 1983. 16. Parker S, Cobur P, Lawrence C, et al: A randomized double-blind comparison of PUVA-etretinate and PUVAplacebo in the treatment of chronic plaque psoriasis. Br J Dermatol 110:215-220, 1984.
Photochemotherapy (PUVA) and skin cancer To the Editor: We would like to share our experience in the use of photochemotherapy (PUVA) for the treatment of psoriasis and the development of cutaneous tumors. Our psoriasis treatment center began operation in August 1977. Treatment offered at that time included day care, outpatient modified Goeckerman and PUVA therapies. After 7 years of operation, we reviewed the records of 2,197 new patients seen at our center. Of these patients, 1,970 had psoriasis. Three hundred six patients (15%) received PUVA therapy as a primary fonn of treatment or were converted to PUVA after failure on other forms of treatment. Of the 306 patients treated with PUVA, 205 (67%) were stilI undergoing PUVA therapy at the time of review of records. They had all been examined within 6 months of chart review. In this PUVA group, the following information is considered relevant: Longest period of time under PUVA therapy for anyone patient Highest number of treatments given to anyone patient Highest cumulative joule dosage received by any one patient
7 years 223 3,841
Four of 205 patients developed the foIlowing tumors: Basal cell carcinoma Squamous cell carcinoma Dysplastic nevus
I 2 1
This represents an incidence of 0.97% basal cell carcinoma (2 of 205 patients), 0.48% squamous cell carcinoma (1 of 205 patients), and 0.48% dysplastic nevus (l of 205 patients) in our group of patients. The four PUVA patients who developed cutaneous tumors had all had years of natural ultraviolet exposure, as well as exposure to tars and artificial ultraviolet B (UVB). None had had exposure to arsenic. Both patients with squamous cell carcinoma had had previous methotrexate treatment. One of these patients with squamous cell carcinoma had also had grenz ray treat-
Correspondence
We dermatologists need to critically examine this issue of undressing patients and the interrelated issue of our responsibility in regard to finding lesions unsuspected by the patient and unrelated to the presenting complaint. I believe this problem should be examined by one of the task forces of the American Academy of Dermatology. Ernst Epstein, M.D. 100 South Ellsworth Ave.', Suite 707 San Mateo, CA 94401
Reply To the Editor: Dr. Kaminester's letter is timely in view of the American Academy of Dermatology's National Melanoma/ Skin Cancer Screening Program this year. I applaud his determined and obviously successful effort to give each of his new patients the optimum of dermatologic expertise by doing a complete skin examination at the first visit. The American Academy of Dermatology (AAD) recommends a complete skin examination annually. The AAD and the American Cancer Society are publishing a skin self-examination technic for malignant melanoma. The technic, developed by AAD members Alfred W. Kopf, M.D., Robert J. Friedman, M.D., and Darrel S. Rigel, M.D., will appear in the May/June 1985, issue of Ca: A Cancer Journal for Clinicians, a publication of the American Cancer Society. The method of introducing the complete skin examination will vary from physician to physician. Some dermatologists may find Dr. Kaminester's "Dear Patient" letter convenient while others may prefer a less structured method. If patients decline the complete examination, they could be invited to be prepared to spend a few extra minutes for the examination at their next visit. The American dermatologists may take advantage of the annual complete skin examination to teach their patients the technic for skin self-examination. Skin examinations by the patient at regular intervals and annual examinations by the dermatologist should result in an informed population, alert to the earliest signs of cancer and melanoma. With early detection and treatment, the prospects for preventing death from melanoma and skin cancer are excellent. Faye D. Arundell, M.D. 825 Oak Grove Ave., Suite D101 Menlo Park, CA 94025
153
Oral isotretinoin followed by psoralens and ultraviolet A or ultraviolet B for psoriasis To the Editor: Systemic retinoid therapy has been used in the past decade for the treatment of psoriasis, acne, ichthyosis, and other disorders of keratinization. 1·4 For psoriasis, the most effective compound has been the aromatic retinoid etretinate (Tegison, USA; Tigason, Europe),s and since the late 1970s investigators have attempted to minimize the dose by combining it with other therapeutic modalities. Clearing of psoriasis is enhanced when etretinate is combined with psoralens and ultraviolet A (PUVA)6'8 or ultraviolet B (DVB).9 Recently, chemically related isotretinoin has been shown to enhance the responsiveness of psoriasis to PUVA. IO We studied isotretinoin followed by DVB or PUVA for the treatment of psoriasis to determine if this would minimize duration of therapy as well as ultraviolet exposure. Methods. Our randomized prospective study involved groups of psoriatic patients who had discontinued all therapy for 2 weeks. Based on clinician's judgment, patients were placed in group A (UVB 5 to 7 times per week), group B (PUVA 3 times per week), or group C (UVB 3 times per week). Patients then randomly received isotretinoin or no therapy prior to UV therapy. Isotretinoin was discontinued after 4 weeks, at which time UVB or PUVA was initiated. Therapy was continued until clearing. A total of sixty-eight patients were entered into the study. Patients in group A generally required hospitalization while those in group C were outpatients. The dosage of isotretinoin in all groups was approximately 1 to 2 rng/kg/day, generally resulting in a dose of 40 mg twice daily. DVB therapy was individualized based on the patient's skin type and response to therapy. PUVA patients, group B, were outpatients treated three times weekly. All PUVA patients were given 8-methoxypsoralen (30-60 mg) 2 hours prior to administration of UVA. All patients were studied to clearing unless they failed therapy. Results. Results for all groups are summarized in Table I. Patients in group Al required an average of 286 minutes of UVB therapy compared with 366 minutes of DVB for those in group A2. Although a trend was evident, this difference is not significant (based on Student's t test; p < 0.05). In group Cl, the total minutes of DVB to clearing was 323, while in group C2, 407 minutes of DVB were required. This difference was not statistically significant (p < 0.05). Patients in group B1 also showed no statistically significant decrease in total UVA exposure compared with those in group B2. Total UVA dose in group Bl averaged 195 joules/cm~ with an average of 17.4 treatments. Total UVA dose in group B2averaged 185
154
Journal of the American Academy of Dermatology
Correspondence
Table I. Summary results of patient that cleared Group
Al (n A2 (n
= 6) = 7)
Bl (n = 10) B2 (n = 9) Cl (n C2 (n
= 6) = 9)
Average % body involved
Average No. of
64 66
30.7 25.8 NS (p < 0.05) 17.4 16.5 NS (p < 0.05) 40.8 36.6 NS (p < 0.05)
55 47 30 36
Rx
Average total UVA (joules/em')
Average total UVB (min)
286 366 NS (p < 0.05) 195 185 NS (p < 0.05) 323 407 NS (p < 0.05)
NS: Not significant. Group A (UVB 5 to 7 times weekly); group B (PUVA); group C (UVB 2 to 3 times weekly). Subgroup 1 (isotretinoin); subgroup 2 (control).
joules/cm2 with an average of 16.5 treatments. Some patients in each of the three groups treated with isotretinoin seemed to show dramatic improvement; however, others became worse, producing a wide range of total ultraviolet light (UVL) required to clear. One patient suffered a significant flare on isotretinoin and dropped out, suggesting that any tendency to improvement on the drug may result from a skewed treatment group. Four patients had significant elevation of serum triglyceride and cholesterol levels and required discontinuation of the isotretinoin. The other expected side effects, including dryness and epistaxis from isotretinoin, were seen in all patients receiving the drug. Discussion. The advantages of combination therapy are readily apparent. One concern of UVL therapy is the increased risk of skin carcinoma, so a reduction of UVL exposure in psoriatics would be beneficial. In addition, isotretinoin is associated with bony abnormalities like hyperostosis II and premature epiphyseal closure1 2 with chronic administration. Since psoriasis is not a curable disease and repeated exposures to these therapies can be expected, a decreased cumulative dose or duration of therapy can only be helpful. The effects of retinoids have not been clearly delineated. The obvious side effects show clinically apparent skin changes. Studies of skin fragility show that retinoids cause fraying or loss of stratum corneum and outer epidermis as well as a loss of desmosomes and tonofilaments. 13 Studies on the effect of isotretinoin on cultured keratinocytes have shown that it retards colony fonnation and increases cell shedding. 14 These cells are less stratified with fewer cell layers and are less differentiated. 15 Most patients in groups AI, Bl, and Cl had little
or no response to isotretinoin alone, and some actually flared. One patient with severe psoriasis did have a dramatic improvement in response to isotretinoin alone. He then flared when PUVA was begun and subsequently was maintained just on isotretinoin. Two patients in group B failed PUVA alone after 3 months. Later they were pretreated with isotretinoin, off protocol, prior to PUVA, both completely clearing. Honigsmann and Wolff1o reported sixty patients with severe psoriasis randomly assigned to groups receiving isotretinoin or etretinate followed by PUVA. Both retinoids were administered orally at daily doses of 1.0 mg/kg for 5 days before PUVA therapy was started. Retinoid therapy continued until psoriasis had cleared completely, at which time the retinoids were discontinued and patients were put on PUVA maintenance therapy. They found no difference between groups (isotretinoin/PUVA vs etretinate/PUVA) when comparing duration of therapy, number of treatments to clearing, and total dose (joules/cm2). There was a significant difference when compared to previous reports of PUVA alone. Others l6 have shown no augmentation of response of psoriasis to PUVA by etretinate. Our results do not support pretreatment of isotretinoin prior to PUVA or UVB in the treatment of psoriasis. Other studies have found a synergistic effect when using isotretinoin or etretinate in combination with PUVA or UVB. Although there was improvement in isolated cases, it seems more likely that the effects of isotretinoin are reversible and do not last through an entire course of UVL. Isotretinoin will affect psoriasis, but improvement of the disease is not significant for most patients unless concomitantly augmented with UVB or PUVA. This would most likely minimize long-
Volume 13 Number 1 July, 1985
tenn effects of both therapies and should be considered in cases of recalcitrant disease.
Randall K. Roenigk, MD. Department of Dermatology University of Minnesota, Minneapolis, MN 55455 Connie Gibstine, M.D., and Henry H. Roenigk, Jr., MD. Department of Dermatology Northwestern University Medical School Chicago, IL 60611 REFERENCES 1. Goldsmith LA, Weinrich AE, Shupack J: Pityriasis rubra pHaris response to 13-cis-retinoic acid (isotretinoin). J AM ACAD DERMATOL 6:710-715, 1982. 2. Baden HP, Buxman MM, Weinstein GD, Yoder FW: Treatment of ichthyosis with isotretinoin. J AM ACAD DERMATOL 6:716-720, 1982. 3. Dicken CH, Bauer EA, Hazen PG, et al: Isotretinoin treatment of Darier's disease. J AM ACAD DERMATOL 6:721-726, 1982. 4. Bergfeld WF, Derbes VJ, Elias PM, et al: The treatment of keratosis palmaris et plantaris with isotretinoin. J AM ACAD DERMATOL 6:727-731, 1982. 5. Ehmann CW, Voorhees JJ: International studies of the efficacy of etretinate in the treatment of psoriasis. J AM ACAD DERMATOL 6:692-696, 1982. 6. Grupper C, Berretti B: Treatment of psoriasis by oral PUVA therapy combination aromatic retinoid (re-PUVA), in Orfanos CE, Braun-Falco 0, Farber EN, et ai, editors: Retinoids-advances in basic research and therapy. Berlin, 1981, Springer-Verlag, pp. 341-345. 7. Lauranta J, Juvakoski T, Kaneruva L, Lassus A: Aromatic retinoid (Ro 10-9359), re-PUVA and PUVA in the treatment of psoriasis, in Orfanos CE, Braun-Falco 0, Farber EM, et ai, editors: Retinoids-advances in basic research and therapy. Berlin, 1981, Springer-Verlag, pp. 201-205. 8. Wolff K, Fritsch PO: Retinoid-PUVA chemo-photochemotherapy, in Farber EM, Cox AJ, editors: Psoriasis: Proceedings of the Third International Symposium, 1981. New York, 1982, Grune & Stratton, Inc., pp. 211-219. 9. Boer J, Suurmond D: Combined UVB phototherapy and low dose oral retinoid Ro 10-9359 for psoriasis responding inadequately to DVB alone, in Orfanos CE, BraunFalco 0, Farber EM, et ai, editors: Retinoids-advances in basic research and therapy. Berlin, 1981, SpringerVerlag, pp. 439-442. 10. Honigsmann H, Wolff K: Isotretinoin-PUVA for psoriasis. Lancet 1:236, 1983. (Letter to Editor.) 11. Pittsley RA, Yoder FW: Skeletal toxicity associated with long-term administration of 13-cis-retinoic acid for refractory ichthyosis. N EnglJ Med 308: 1012-1014, 1983. 12. MHstone LM, McGuire J, Ablow RC: Premature epiphyseal closure in a child receiving oral 13-cis-retinoic acid. J AM ACAD DERMATOL 7:663-666, 1982. 13. Williams ML, Elias PM: Nature of skin fragility in patients receiving retinoids for systemic effect. Arch Dermatol117:611-619, 1981.
Correspondence 155
14. McGuire J, Fedarko N, Johanssen E, et al: The influence of retinoids on cultivated human keratinocytes. J AM ACAD DERMATOL 6:630-639, 1982. 15. Kubilus J: Modulation of differentiation by retinoids. J Invest Dermatol 81:555-585, 1983. 16. Parker S, Cobur P, Lawrence C, et al: A randomized double-blind comparison of PUVA-etretinate and PUVAplacebo in the treatment of chronic plaque psoriasis. Br J Dermatol 110:215-220, 1984.
Photochemotherapy (PUVA) and skin cancer To the Editor: We would like to share our experience in the use of photochemotherapy (PUVA) for the treatment of psoriasis and the development of cutaneous tumors. Our psoriasis treatment center began operation in August 1977. Treatment offered at that time included day care, outpatient modified Goeckerman and PUVA therapies. After 7 years of operation, we reviewed the records of 2,197 new patients seen at our center. Of these patients, 1,970 had psoriasis. Three hundred six patients (15%) received PUVA therapy as a primary fonn of treatment or were converted to PUVA after failure on other forms of treatment. Of the 306 patients treated with PUVA, 205 (67%) were stilI undergoing PUVA therapy at the time of review of records. They had all been examined within 6 months of chart review. In this PUVA group, the following information is considered relevant: Longest period of time under PUVA therapy for anyone patient Highest number of treatments given to anyone patient Highest cumulative joule dosage received by any one patient
7 years 223 3,841
Four of 205 patients developed the foIlowing tumors: Basal cell carcinoma Squamous cell carcinoma Dysplastic nevus
I 2 1
This represents an incidence of 0.97% basal cell carcinoma (2 of 205 patients), 0.48% squamous cell carcinoma (1 of 205 patients), and 0.48% dysplastic nevus (l of 205 patients) in our group of patients. The four PUVA patients who developed cutaneous tumors had all had years of natural ultraviolet exposure, as well as exposure to tars and artificial ultraviolet B (UVB). None had had exposure to arsenic. Both patients with squamous cell carcinoma had had previous methotrexate treatment. One of these patients with squamous cell carcinoma had also had grenz ray treat-