Mild-to-Moderate Psoriasis - part 6 pptx

70 mg. Following oral administration, there are significant inter- and intraindividual variations in the absorption of 8-MOP. Therefore, it is very important that the psoralen dose, type and amount of food intake , and tim- ing of phototherapy after ingestion of psoralen are kept constant. Psoralen is preferable to be taken on an empty stomach, as food intake slows absorp- tion and reduces the peak blood levels. However, due to gastrointestinal side effects, especially with 8-MOP, non-fat small meals may be taken to allevi- ate some of these symptoms. In some patients, the capsules may have to be ingested 10 minutes apart to minimize the gastrointestinal side effects. Antiemetics may have to be given to some pa tients. In patients who are unable to tolerate systemic PUVA, psoralen can be administered in a bath or cream /lotion, avoiding the gastrointestinal tract. In our institution, topical PUVA is administered using 0.1% 8-MOP solution in Lubriderm 1 lotion, applied 20 minutes prior to exposure to UVA. The UVA dose protocol is shown in Table 3. Bath PUVA is only performed in very few centers in the United States because of the need for a bathtub. A bath containing 0.5–5.0 mg/L of 8-MOP, or 0.33 mg/L of TMP, needs to be freshly prepared; the patient will then soak in it for 15 to 30 minutes. At some phototherapy facilities [e.g., University of California, San Francisco (UCSF)], effective bath PUVA is being conducted simply by dissolving 50 mg of Oxsoralen Ultra in a hot cup of water first and then adding it to 100 L of bath water. Exposure to the UVA needs to be performed within 30 minutes after the patient steps out of the bathtub. In Europe, oral 5-MOP is commonly used. It is less phototoxic than 8-MOP, therefore requiring a higher cumulative UVA dose. The dose range used is 1.2–1.8 mg/kg. It has less of a gastrointestinal side effect, hence is better tolerated. It is not available in the United States. Avoidance of prolonged sun exposure and wearing UVA-ab sorbing sunscreens on the days of PUVA therapy are necessary to prevent significant phototoxicity. Unlike UVB-induced erythema, PUVA-induced phototoxic- ity begins approximately 24 hours after exposure and peaks at 48–72 hours after exposure. This is the reason that PUVA should not be administered two days in a row. If PUVA is administered on consecutive days, a treatment Table 3 Topical Psoralen and Ultraviolet A Protocol 0.1% methoxypsoralen in Lubriderm 1 lotion is applied to the affected areas 20–30 min prior to treatment. This is only applied in the medical office The initial dose of UVA is 0.25–0.5 J/cm 2 The dose increase is based on side effects. If tolerated, increase by 0.25–0.5 J/cm 2 Photochemotherapy is given three times per week The maximum dose is 8 J/cm 2 Once the condition has improved, treatment frequency can be decreased to twice per week for 4–8 weeks and then once per week for 4–8 weeks, then discontinued 134 Kerr et al. protocol more often used in Europe, the dose is kept constant on the first two days of the week, followed by a nontreatment third day; an increased but identical dose may be given on the fourth and fifth day of the week (34). The initial dose of UVA can either be determined by minimal photo- toxicity dose (MPD) or more commonly by Fitzpatrick skin type. The MPD is the minimal dose of PUVA that produces well-defined erythema. These readings are performed at 48–72 hours. The skin-type–based protocol used at our institution is shown in Table 4. The dose of UVA should be adjusted, usually decreased by 25%, if patien ts are taking photosensitizing medica- tions. UVA doses should also be decreased if topical or systemic retinoids are used during a course of PUVA because they thin the stratum corneum, reducing the amount of light required for phototoxicity. During the UVA exposure, protective eyewear should be used. Male genitalia are particular ly sensitive to the development of squamous cell car- cinomas (SCCs) (41); male genitals should be shielded during all of the UVA exposure. If PUVA is required for limited disease, careful shielding of unaf- fected skin is recommended. Therapy is usually administered twice to three times per week until the psoriasis is well controlled; it then can be decreased to twice and eventually once a week. Maintenance therapy ha s been shown to decrease the probabil- ity of remission; however, it will increase the patient’s cumulative dose of UVA. The British Phototherapy Group recommends that long-term PUVA therapy should only be considered in patients with a history of rapid relapses (42). However, whether this applies to non-Caucasians is not clear. To better define the frequency of PUVA therapy, a prospective, randomized, half-side study was performed in Austria, using 18 patients with chronic plaque psoriasis who received paired PUVA regimens (43). It was shown that reducing the number of treatments while maintaining the same UVA dose per week did not reduce efficacy. Reducing the number of treatments from four times per week to twice a week and reducing the UVA dose from 1 to 0.75 or 0.5 MPD per treatment only slightly affected Table 4 Guideline for Psoralen and Ultraviolet A Photo- chemotherapy for the Treatment of Psoriasis Based on Skin Type Skin type Initial dose (J/cm 2 ) Dose increase per treatment (J/cm 2 ) Maximum dose (J/cm 2 ) I 0.5 0.5 8 (4-face) II 1.0 0.5 8 (4-face) III 1.5 1.0 12 (4-face) IV 2.0 1.0 12 (4-face) V 2.5 1.5 20 (4-face) VI 3.0 1.5 20 (4-face) Phototherapy and Laser Treatment 135 intermediate therapeutic efficacy, and had no effect on final clearance rates or time to complete clearance. The mean cumulative UVA dose was signifi- cantly lower for the least intensive dose regimen (0.5 MPD twice/wk) than for the more intensive regimens. Due to the increased development of cutaneous malignancies with PUVA therapy, one should strongly consider the combination with other drugs such as retinoids or in rotation with other treat ments to minimize total cumulative dose of PUVA. Adverse Effects The acute side effects can be due to either the psoralen or the UVA radia- tion. Systemic psoralen causes nausea and occasionally vomiting in up to 30% of patients taking 8-MOP. 5-MOP has fewer gastrointestinal symptoms and is better tolerated. Most drug-i nduced photosensitivities are due to UVA; therefore, a careful medication history will help prevent this adverse event. PUVA-induced phototoxic reactions, such as erythema and vesicula- tion, appear at 24–36 hours and peak at 48–72 hours; they can persist for a week or longer. Other known side effects include photo-onycholysis, mela- nonychia, and friction blisters. Subacute side effects can be an intractable pruritus known as ‘‘PUVA itch.’’ In some patients, therapy may have to be stopped until the pruritus resolves, and one can then consider restarting the treatment with a lower UVA dose. Tannin g is a constant feat ure, espe- cially in patients with darker skin. Long-term side effects include photoaging, the development of small brown to black macules in PUVA-exposed sites, known as PUVA lentigines, and photocarcinogenesis. Many of these long-term side effects have been reported by the PUVA follow-up study, a 16-center prospective cohort study of 1380 patients first treated with PUVA in 1975–1976 in the United States (44). In a study on photo aging, actinic damage was observed in the hands of 61% of patients, and in the buttocks of 21%. Pigmen tary changes were seen in the hands of 59% of patients, and in the buttocks of 25% (45). Increased risk of SCCs is a well-documented dose-dependent adverse effect in Caucasians. In the U.S. 16-center study, there was no increase in non-melanoma skin cancer in the first 15 years of the study. However, after 25 years, 50% of patients who had recei ved greater than 400 treatments had SCC, and 33% of patients who had received greater than 200 treatments had BCC (44). A Swedish study followed 4799 patients who had received PUVA between 1974 and 1985 with an average follow-up period of 15.9 years for men and 16.2 for women; increase in the risk for SCC was also observed: the relative risk for SCC was 5.6 for men and 3.6 for women (46). In contrast, a meta-analysis of all availab le long-term data on non-Caucasians with respect to non-mel anoma skin cancer so far revealed no increase in risk in non-melanoma skin cancer in non-Caucasians (47). 136 Kerr et al. There is a significant dose-dependent increase in SCC in the genitals of PUVA-treated male patients. The incidence of invasive penile and scrotal SCCs was increased by 52.6-fold. This dose-dependent increase in the risk of genital tumors is persistent long after PUVA therapy has been stopped, especially among those with high-dose exposures to both PUVA and tar or UVB (41). There are conflicting results on long-term studies on the incidence of melanoma after PU VA therapy. The PUVA follow-up study reported an increased risk of melanoma, greatest in patients exposed to high doses of PUVA (!250 treatments), beginning 15 years after first exposure to PUVA. The incidence rate ratio was 8.4 (48). In contrast, the Swedish follow-up study of 4799 patients who had received PUVA between 1974 and 1985 with an average follow-up period of 15.9 years for men and 16.2 for women did not find an increased risk for melanoma, nor in a subcohort co mprising 1867 patients followed for 15–21 years (46). In another study by the U.S. PUVA follow-up group of over 1000 patients treated with PUVA, UVB exposure (!300 treatments vs. <300 treat- ments)wasassociatedwithamodestbutsignificantincreaseinSCCandBCC risk (49). These occurred on body sites typically exposed to UVB therapy, but not on chronically sun-exposed sites typically covered during therapy. Using the U.S. PUVA follow-up database, 135 patients who had used oral retinoids for greater than 26 weeks in one year were studied. The devel- opment of SCC and BCC for each patient during the retinoid use year was compared to the non-retinoid use years. It was found that oral retinoids reduced the risk of SCC but did not significantly alter BCC incidence (50). TARGETED (LOCALIZED) PHOTOTHERAPY The appeal of targeted, or localized, phototherapy is its ability to spare healthy skin from the side effects of UV radiation. In addition, the affected areas can usually tolerate a higher dose than unaffected skin, as the rate- determining factor for generalized phototherapy is usually erythema of uninvolved skin. It is known that normal skin can be exposed to up to three MEDs without blistering, while psoriatic skin may be exposed to up to three times this dose (nine MEDs) without blistering (51,52). The recent commercial introduction of fiber-coupled UVB phototherapy systems facil- itates the use of this treatment modality for localized psoriasis plaques. The mechanism of action of targeted phototherapy is similar to that of the other UV-based therapy, namely by inducing T-cell apoptosis, suppression of DNA synthesis, and generation of prostaglandins and cytokines. It has been reported that the 308 nm excimer laser is more effective in the induction of T-cell apoptosis compared to NB-UVB (6). At the time of this writing, there are several targeted phototherapy systems available (Table 5): XTrac excimer laser system (PhotoMedex, Phototherapy and Laser Treatment 137 Table 5 Targeted Ultraviolet A and Ultraviolet B Phototherapy Units Phototherapy unit Company UV type Wavelength (nm) Spot size (cm) Other features Xtrac TM PhotoMedex Xenon chloride laser 308 1.8 Â 1.8 circular BClear TM Lumenis TM UVB 290–320 1.6 Â 1.6 square Portable DuaLight TM Theralight TM , Inc. UVB and UVA 290–330; 330–400 1.9 Â 1.9 square Can switch from UVB to UVA, compact Lovely II TM MSQ Ltd. UVB 300–380 4.0 Â 1.6 MultiClear TM CureLight Ltd. UVB, UVA, and visible 295–315; 360–370; 405–450 2.3 Â 2.3 Portable T 500x Daavlin UVA and UVB 290–330; 330–400 1.5 Â 1.5 square Compact, portable Excilite-m TM National Biological UVB Peak: 308 30 cm square Portable Abbreviations: UVA, ultraviolet A; UVB, ultraviolet B. 138 Kerr et al. Montgomeryville, Pennsylvania, U.S.A.), BClear targeted photoclearing system (Lumenis, Santa Clara, California, U.S.A.), DuaLight UVA/UVB phototherapy system (TheraLight Inc., Carlsbad, California, U.S.A.), Lovely II (MSq Ltd., Caesarea, Israel), MultiClear (Curelight Ltd., Margate, Florida, U.S.A.), T-500x (Daavlin, B ryan, O hio, U.S.A.), Excilite-m (National Biological Corporation, Twinsburg, Ohio, U .S.A.). XTrac is the only laser- targeted phototherapy system; the rest are non-laser light sources. Efficacy Most of the published studies on targeted phototherapy have been performed with the 308 nm excimer laser system, which will be the focus of the discus- sion in this section. There are not a lot of published studies on the other UV phototherapy machines; however, because their wavelengths are similar to that of BB-UVB, NB-UVB, or UVA, theoretically they should be as efficacious as booth phototherapy. Initial case reports and subsequent larger studies (53) have shown significant improvement and even remission of psoriatic lesions following exposure to the 308 nm excimer laser. In a multicenter study of 80 patients, stable mild to moderate plaque-type psoriasis was treated twice per week for a total of 10 treatments or clear disease (54). The initial dose was based on MED testing and the following treatments were based on plaque response. Seventy-two percent achieved at least 75% clearing in an average of 6.2 treatments. Eighty-four percent of patients reached improvement of at least 75% after 10 or fewer treatments. Fifty percent reached improvement of at least 90% after 10 or fewer treatments. In a follow-up study, 55% of patients reported an overall satisfaction with their treatments and 25% reported that their treatment was better than other therapies they had tried for localized disease (55). Higher doses can be used on psoria tic plaques with faster clearing and decreased cumulative dose as compared to conventional booth phototherapy (56). A dose-response study showed clearance of psoria sis with high fluences (8–16 times MED) in as little as one treatment (52). Koebner reactions were not observed despite the side effects of transient painful blistering. Treatment with higher fluences was more effective than with low and medium fluences. In addition, the lesions treated with high fluences remained in remission longer. The four-month relapse-free outcome is comparable or better than the standard topical or systemic therapy for psoriasis (52). In a study with four children with psoriasis, mean age 11, the excimer laser was found to be a safe and effective treatment for localized psoriasis in these childr en (57). Two studies have compared the excimer laser to incoherent UVB phototherapy with similar outcomes. Tanghetti and Gillis (58) compared the clinical outcome of treatment with the excim er laser to a continuous- wave, incoherent UVB light source. Both systems cleared the treated psoriasis plaques equivalently, requiring no more than two to five weeks Phototherapy and Laser Treatment 139 of treatment. When used at equally erythemogenic high doses, both systems produced rapid plaque clearance with minimal side effects. Ko ¨ llner et al. (59) treated 15 patients with plaque psoriasis. Three different psoriatic lesions were treated with either the xenon chloride 308 nm excimer laser, the 308 nm excimer lamp, or 311 nm NB-UVB three times per week. UVB doses were increased slowly and stepwise. There was no statistically significant difference among the three groups after 10 weeks. The mean number of treat- ments needed to achieve clearance was 24. Both 308 nm light sources treated psoriasis with a similar efficacy to standard NB-UVB phototherapy. Combination The rapy To date, there are no published studies on the combination of targeted phototherapy with adjunctive treatment. Indications Targeted phototherapy is ideal for localized mild to moderate psoriasis, including lesions on palms and soles, and on scalp. Contraindications There are no absolute contrai ndications. Contraindications are related to the corresponding wavelength. Advantages and Disadvantages The advantages of targeted phototherapy include sparing healthy tissue from UV radiation and ability to deliver high fluences to affected areas. This could result in faster rate of response, and probably less cumulative dose. However, the time to administer therapy is greatly increased as compared to booth phototherapy. One can spend up to 20 minutes per session twice to three times per week. Under appropriate supervision, the therapy can be delivered by an experienced nurse, phototherapy technician, or physician. Dosage and Administration This topic has been studied most extensively with the 308 nm excimer laser. There are various treatment regimes reported and this is still an area of active investigation. Treatments are usually delivered twice or three times per week. The initial dosing is usually based on a predetermined MED as well as plaque thickness and location. Fluences should be adjusted according to symptoms and response to treatment. The initial dose is usually maintained until the plaques flatten, at which point the dose is decreased. Likewise, if there is no improvement with the initial dose, the fluence should be increased. 140 Kerr et al. Housman et al. (60), have found that twice-weekly excimer laser treat- ments promote clearance of psoriatic plaques and tapering the treatments may be beneficial in maintaining the level of plaque clearance obtained from biweekly laser treatments. Ko ¨ llner et al. (59) treated 16 patients with the 308 nm excimer laser or with the 308 nm lamp with an accelerated scheme three times per week. They compared this with UVB therapy in which the dose was increased every sec- ond treatment. With the accelerated scheme, clearance was achieved with fewer treatments and with half the cumulative dose of a slow and stepwise regime. The side effects such as blistering and crusting were also increased. Adverse Effects The adverse effects of targeted phototherapy are related to the wavelength administered. The lesional and perilesional skin can develop erythema, tan- ning, vesiculation, erosion, or crusting. This may result in an uneven skin tone and may be a cosmetic concern for some patients. This dyspigmentation fades gradually with time once phototherapy is stopped. Interestingly, koebneriza- tion has not been reported with vesiculation. In fact, just the opposite, faster clearance in the vesiculated areas or a ‘‘reverse’’ Koebner phenomenon has been reported. There are no long-term studies on carcinogenesis. ULTRAVIOLET A1 UVA1 is a relatively new type of phototherapy in the United States; how- ever, it has been used since the early 1990s in Europe. Its main indications are for the treatment of atopic dermatitis and sclerosing disorde rs. Efficacy There are two small studies published on the use of UVA1 for the treatment of psoriasis. Kowalzick et al. (61) performed a paired controlled trial in three patients using medium dose UVA1 and BB-UVB for three weeks. Both the UVA1- and BB-UVB–treated lesions improved. A review cited three HIV- positive psoriatic patients who benefited from UVA1 phototherapy (62). However, in a review of Mang and Krutmann’s (63) personal experience, there is little to no efficacy of UVA1 for the treatment of psoriasis. It has been suggested that UVA1 is the phototherapy of choice for HIV-positive patients with psoriasis (63). Three HIV patients with psoriasis were treated with high dose (130 J/cm 2 ) UVA1 with benefit. A quantitative polymerase chain reaction (PCR)-based assay was performed in both lesional and nonlesional skin after one UVB or UVA1 exposure. The UVB-treated skin showed a 6–15-fold increase in the HIV copy number, whereas the UVA1-treated skin did not show any increase (62). Further studies are clearly needed. Phototherapy and Laser Treatment 141 Combination The rapy To our knowledge, there have been no published studies looking at the com- bination of UVA1 with other therapies. Indications The indications for UVA1 for psoriasis are not clear, as further investiga- tions are necessary to determine its efficacy. Contraindications Contraindications include photodermatoses with action spectrum in the UVA1 range. In patients taking photosensitizing medications, UVA1 needs to be used with caution. Advantages and Disadvantages Further studies are necessary. Dosage and Administration Until further study with psoriasis shows good efficacy, there is no established dose for this treatment. For atopic dermatitis and localized scleroderma, stud- ies have been done using low dose (20 J/cm 2 ), medium dose (50–60 J/cm 2 ), and high dose (120 J/cm 2 ). The low and medium doses are the more com- monly used regimen at the present time. Adverse Effects UVA1 is generally well tolerated. Exposed skin will become tanned. There is a significant amount of heat generated by the equipment throughout the treatment. Other possible side effects include xerosis, pruritus, and rarely skin burning. The long-term side effects are not known. In animal models, UVA1 has induced squamous cell cancers (64). CONCLUSION Phototherapy and photochemotherapy have a role in the treatment of localized and generalized psoriasis. Patient compliance and the ability for the patient to come to the office regularly for the treatment are factors that need to be considered. Targeted phototherapy sparing uninvolved skin is a new development that is beneficial for selected patients. The side effects of PUVA are well established. UVB, when judiciously administered, has mini- mal side effects. 142 Kerr et al. REFERENCES 1. Krueger JG, Wolfe JT, Nabeya RT, et al. Successful ultraviolet B treatment of psoriasis is accompanied by a reversal of keratinocytes pathology and by selec- tive depletion of intraepidermal T cells. J Exp Med 1995; 182(6):2057–2068. 2. Ozawa M, Ferenczi K, Kikuchi T, et al. 312-nanometer ultraviolet B light (narrow-band UVB) induces apoptosis of T cells within psoriatic lesions. J Exp Med 1999; 189(4):711–718. 3. Johnson R, Staiano-Coico L, Austin L, et al. PUVA treatment selectively induces a cell cycle block and subsequent apoptosis in human lymphocytes. Photochem Photobiol 1996; 63(5):566–571. 4. Bianchi B, Campolmi P, Mavilia L, et al. Monochromatic excimer light (308 nm): an immunohistochemical study of cutaneous T cells and apoptosis-related mole- cules in psoriasis. J Eur Acad Dermatol Venereol 2003; 17(4):408–413. 5. Morita A, Werfel T, Stege H, et al. Evidence that singlet oxygen-induced human T helper cell apoptosis is the basic mechanism of ultraviolet-A radiation photo- therapy. J Exp Med 1997; 186(10):1763–1768. 6. 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 B 2002; 67(1):32–38. 7. Parrish JA, Jaenicke KF. Action spectrum for phototherapy of psoriasis. J Invest Dermatol 1981; 76(5):359–362. 8. Coven TR, Burack LH, Gilleaudeau R, et al. Narrowband UV-B produced superior clinical and histopathological resolution of moderate-to-severe psoriasis in patients compared with broadband UV-B. Arch Dermatol 1997; 133(12): 1514–1522. 9. Gordon PM, Diffey BL, Matthews JNS, et al. A randomized comparison of narrow-band TL-01 phototherapy and PUVA chemotherapy for psoriasis. J Am Acad Dermatol 1999; 41:728–732. 10. Tanew A, Radakovic-Fijan S, Schemper M, et al. Narrowband UV-B photother- apy vs photochemotherapy in the treatment of chronic plaque-type psoriasis: a paired comparison study. Arch Dermatol 1999; 135(5):519–524. 11. Markham T, Rogers S, Collins P. Narrowband UV-B (TL-01) phototherapy vs 8-methoxypsoralen psoralen-UV-A for the treatment of chronic plaque psoriasis. Arch Dermatol 2003; 139(3):325–328. 12. Dawe RS, Cameron H, Yule S, et al. A randomized controlled trial of narrow- band ultraviolet B vs bath-psoralen plus ultraviolet A photochemotherapy for psoriasis. Br J Dermatol 2003; 148(6):1194–1204. 13. Storbeck K, Holzle E, Schurer N, et al. Narrow-band UVB (311nm) versus con- ventional broad band UVB with and without dithranol in phototherapy for psoriasis. J Am Acad Dermatol 1993; 28(2 Pt 1):227–231. 14. Behrens S, Grundmann-Kollmann M, Schiener R, et al. Combination photother- apy of psoriasis with narrow-band UVB irradiation and topical tazarotene gel. J Am Acad Dermatol 2000; 42(3):493–495. 15. Bourke JF, Iqbal SJ, Hutchinson PE. The effects of UVB plus calcipotriol on systemic calcium homeostasis in patients with chronic plaque psoriasis. Clin Exp Dermatol 1997; 22(6):259–261. Phototherapy and Laser Treatment 143 [...]... Chang Y, et al 308-nm excimer laser for the treatment of psoriasis: a dose-response study Arch Dermatol 2000; 1 36( 5) :61 9 62 4 53 Gerber W, Arheilger B, Ha TA, et al Ultraviolet B 308-nm excimer laser treatment of psoriasis: a new phototherapeutic approach Br J Dermatol 2003; 149 (6) :1250–1258 54 Feldman SR, Mellen BG, Housman TS, et al Efficacy of the 308-nm excimer laser for the treatment of psoriasis: results... of psoriasis: results of a multicenter study J Am Acad Dermatol 2002; 46: 900–9 06 55 Rodewald EJ, Housman TS, Mellen BG, et al Follow-up survey of 308-nm laser treatment of psoriasis Lasers Surg Med 2002; 31(3):202–2 06 56 Trehan M, Taylor CR High-dose 308-nm excimer laser for the treatment of psoriasis J Am Acad Dermatol 2002; 46( 5):732–737 57 Pahlajani N, Katz BJ, Lozano AM, et al Comparison of the... Choi J, Koo JY Quality of life issues in psoriasis J Am Acad Dermatol 2003; 49(suppl 2):S57–S61 31 Mrowietz U Advances in systemic therapy for psoriasis Clin Exp Dermatol 2001; 26( 4): 362 – 367 32 Marchetti A, Feldman SR, Kimball AB, et al Treatments for mild-to-moderate recalcitrant plaque psoriasis: expected clinical and economic outcomes for firstline and second-line care Dermatol Online J 2005; 11(1):1... excimer lamp with 311-nm narrowband ultraviolet B in the treatment of psoriasis Br J Dermatol 2005; 152(4):750–754 60 Housman TS, Pearce DJ, Feldman SR A maintenance protocol for psoriasis plaques cleared by the 308 nm excimer laser J Dermatol Treat 2004; 15(2):94–97 61 Kowalzick L, Suckow M, Waldmann T, et al Mitteldosis-UV-A1 versus UV-BTherapie bei Psoriasis Z Dermatol 1999; 185:92–94 62 Krutmann J, Stege... 1991; 25(4) :68 2 68 4 56 Ruzicka T, Sommerburg C, Braun-Falco O, et al Efficiency of acitretin in combination with UV-B in the treatment of severe psoriasis Arch Dermatol 1990; 1 26( 4):482–4 86 57 Lebwohl M, Drake L, Menter A, et al Consensus conference: acitretin in combination with UVB or PUVA in the treatment of psoriasis J Am Acad Dermatol 2001; 45(4):544–553 13 Topical Sequential Therapy of Psoriasis. .. A Ultraviolet-A1 phototherapy: indications and mode of action In: Krutmann J, Honigsmann H, Elmets CA, Bergstresser PR, ¨ eds Dermatological phototherapy and photodiagnostic methods Berlin: Springer-Verlag, 2001: 261 –2 76 63 Mang R, Krutmann J UVA-1 phototherapy Photodermatol Photoimmunol Photomed 2005; 21(2):103–108 64 Sterenborg HJ, van der Leun JC Tumorigenesis by a long wavelength UV-A source Photochem... and PUVA photochemotherapy: a combination J Am Acad Dermatol 1998; 38 :68 7 69 0 5 Morison WL Systemic and topical PUVA In: Treatment of moderate to severe psoriasis 2d ed New York, NY: Marcel Dekker, 2003:91–114 6 Grundmann-Kollman M, Ludwig R, Zollner TM, et al Narrowband UVB and cream psoralen-UVA combination therapy for plaque-type psoriasis J Am Acad Dermatol 2004; 50:734–739 7 Park YK, Kim HJ, Koh... severe psoriasis J Am Acad Dermatol 2004; 50:4 16 430 Behrens S, Grundmann-Kollmann M, Schiener R, et al Combination phototherapy of psoriasis with narrow-band UVB irradiation and topical tazarotene gel J Am Acad Dermatol 2000; 42:493–495 Koo JY, Lowe NJ, Lew-Kaya DA, et al Tazarotene plus UVB phototherapy in the treatment of psoriasis J Am Acad Dermatol 2000; 43:821–828 Behrens S, Grundmann-Kollmann... of localized psoriasis in adults and in children: a pilot study Pediatr Dermatol 2005; 22(2): 161 – 165 58 Tanghetti E, Gillis PR Photometric and clinical assessment of localized UVB phototherapy systems for the high-dosage treatment of stable plaque psoriasis J Cosmet Laser Ther 2003; 5(2):101–1 06 59 Kollner K, Wimmershoff MB, Hintz C, et al Comparison of the 308-nm excimer laser and a 308-nm excimer... (re-TL-01) vs etretinate-PUVA (re-PUVA) in the treatment of psoriasis patients Br J Dermatol 1992; 127(1):5–9 21 Spuls PI, Rozenblit M, Lebwohl M Retrospective study of the efficacy of narrowband UVB and acitretin J Dermatol Treat 2003; 14(suppl 2):17–20 22 Paul BS, Momtaz K, Stern RS, et al Combined methotrexate–ultraviolet B therapy in the treatment of psoriasis J Am Acad Dermatol 1982; 7 (6) :758– 762 . 15(2):94–97. 61 . Kowalzick L, Suckow M, Waldmann T, et al. Mitteldosis-UV-A1 versus UV-B- Therapie bei Psoriasis. Z Dermatol 1999; 185:92–94. 62 . Krutmann J, Stege H, Morita A. Ultraviolet-A1 phototherapy:. plaque-type psoriasis: a paired comparison study. Arch Dermatol 1999; 135(5):519–524. 11. Markham T, Rogers S, Collins P. Narrowband UV-B (TL-01) phototherapy vs 8-methoxypsoralen psoralen-UV-A. and relapse rates of narrowband UVB (TL-01) monotherapy vs. etretinate (re-TL-01) vs. etretinate-PUVA (re-PUVA) in the treatment of psoriasis patients. Br J Derma- tol 1992; 127(1):5–9. 21. Spuls