PUVA therapy for the treatment of psoriasis, alopecia, vitiligo

Physiotherapy is considered one of the effective and relatively safe methods of treating many diseases. There is a wide variety of physiotherapeutic procedures that affect the human body in different ways. An interesting area of physiotherapy is phototherapy, in which the therapeutic effect on the human body is carried out using dosed ultraviolet radiation. If ultraviolet irradiation is combined with the intake of special photoactive drugs called psoralens (PUVA therapy), great success can be achieved in the treatment of many difficult-to-treat dermatological diseases.

What is PUVA therapy?

Thus, PUVA therapy is one of the most effective methods of physiotherapeutic treatment of pathologies that damage various layers of the skin. In this case, exposure to ultraviolet rays is used to activate photoactive agents.

The unusual name of the method is actually easy and clear to decipher. The word "PUVA" consists of 3 parts. P stands for the photoactive component psoralen, the letter combination UV stands for ultraviolet rays, the last letter of the abbreviation - the letter "A" - indicates the long-wave part of the spectrum of the light rays used (320-400 nm).

Taking psoralens alone does not have any effect on human skin. After all, to activate photosensitizers, exposure to light rays of a certain spectrum is necessary. In this case, UV radiation, which is characterized by a long wavelength.

Under the influence of UV radiation, photosensitizers interact with the DNA molecules of epidermal cells, as a result of which DNA synthesis in cells decreases. Such an effect only changes the structure of damaged cells, but does not affect their functions. The occurrence of cross-links of psoralens and DNA, reducing the production of proteins and nucleic acids, thereby slows down the pathological growth of cells, and therefore the further development of the disease.

Photosensitizers cause the formation of active forms of oxygen, which damage cell membranes and stimulate metabolic processes involving arachidonic acid. They also participate in chemical reactions aimed at suppressing excessive keratinization (keratinization of cells), as a result of which inflammation subsides, itching and peeling disappear, and the skin becomes soft and elastic again without compactions and crusts.

The effectiveness of the method is confirmed by many positive reviews, of which a great many have accumulated over more than 20 years of the method's existence. PUVA therapy has a stronger therapeutic effect compared to conventional phototherapy without the use of photosensitizers.

Indications for the procedure

The PUVA therapy method has found wide application in dermatology. It is used to treat even those skin diseases that do not respond to conventional drug treatment.

Most often, PUVA therapy is used to treat the following pathologies:

• psoriasis,
• vitiligo,
• atopic dermatitis,
• alopecia (baldness),
• scleroderma,
• mycosis fungoides,
• ichthyosis,
• Bowen's disease,
• eczema,
• parapsoriasis,
• basal cell skin cancer,
• lymphoma,
• papillomas,
• acne vulgaris and other pathologies characterized by pathological changes in skin cells.

Therapy using this method can be prescribed at any stage of the disease.

PUVA therapy is also used to combat the signs of photoaging of the skin of the hands and face. At the same time, the condition of the skin improves and its elasticity increases due to the stimulation of collagen production.

PUVA therapy for various pathologies

Initially, the PUVA therapy method was developed to combat a virtually incurable autoimmune pathology called psoriasis, characterized by the appearance of flaky, itchy areas of keratinized skin on the body, the cause of which was the pathologically rapid growth of cells. Having seen the good effectiveness of the method in the example of psoriasis, doctors began to use it to treat other skin diseases.

PUVA therapy is considered indispensable for the treatment of psoriasis characterized by extensive localization or severe course. We are talking about a pathology in which the total area of skin affected by the disease is from 20 to 30% of the area of the entire skin.

PUVA therapy shows sufficient efficiency in such severe forms of pathology as widespread plaque form, exudative, erythrodermatic and pustular psoriasis, as well as guttate and palmoplantar type of psoriasis, which, due to its localization, causes the greatest discomfort in patients. It is used as a last hope when other methods of combating the disease are ineffective.

PUVA therapy also shows promising results in alopecia. The idea of using this method for treating baldness arose due to a striking feature observed in such patients. In patients who were exposed to sunlight for a short time, hair growth was more active than in those who avoided the open sun. True, there were cases of exacerbation of the disease in the summer, but it was still worth a try.

Treatment of mild to moderate severity of the disease is carried out locally, while severe pathology requires a general approach with irradiation of the entire affected surface.

The results of treatment of many patients with focal alopecia have shown that after 5 and a half months (more precisely 24 weeks) complete hair restoration is observed in 8 out of 9 patients. This is a pretty good indicator.

True, there were cases of relapse of the disease after reducing the radiation dose. Symptoms of the disease appeared 2.5 months after the end of treatment. In order to prevent relapses, topical corticosteroids, aromatic retinoids, anthralin and other drugs are used, allowing for a gradual reduction in the radiation dose without negative consequences.

PUVA therapy is also actively used in the treatment of vitiligo. This pathology is characterized by the disappearance of pigmentation in some areas of the body. Under the influence of PUVA therapy, melanin synthesis is activated in the affected areas and the skin color gradually evens out.

For small light areas of skin, treatment is carried out locally for only 1 or 2 weeks. If the affected area exceeds 20% of the entire skin, a systemic approach is required, and the number of necessary procedures can reach 100, and in some severe cases, 150 procedures.

Positive results in the treatment of vitiligo with PUVA therapy are observed in more than 50% of patients.

Phototherapy can also help patients with connective tissue diseases. For example, PUVA therapy is used for scleroderma. The disease is chronic and manifests itself in the form of compaction and scarring of connective tissue.

The long-wave UV light flux is capable of affecting not only the surface layers of the skin, but also penetrating deep inside. Light energy, transforming into heat, triggers chemical processes that lead to positive changes in the structure of cells. In addition, phototherapy has a bactericidal effect, which prevents inflammatory processes in connective tissue, leading to compaction of skin cells.

The effectiveness of such treatment depends on the dose of radiation and psoralens, as well as on the individual characteristics of the organism. Abroad, the PUVA therapy method has become widespread, since it allows for the treatment of various categories of the population, especially children, with minimal risk to health.

PUVA therapy is considered an effective replacement for corticosteroids in atopic dermatitis (another name is neurodermatitis ), which is one of the types of inflammatory skin diseases. PUVA therapy is used mainly during periods of exacerbation of frequently recurring pathology and mainly in adult patients.

The number of sessions required to relieve the symptoms of an exacerbation of severe neurodermatitis is 59. This is not a small amount, but the results of such treatment are not only good, but also long-term. The main thing is the gradual cancellation of the procedure with a decrease in the dose of UV radiation and psoralens.

In case of a mild course of the disease, 10 - maximum 30 sessions are enough. However, remission after such treatment can last for several years, which significantly improves the quality of life of patients.

We have considered the use of PUVA therapy to combat difficult-to-treat pathologies, but there are many other more or less severe diseases in which PUVA therapy shows decent results, speaking in favor of this method of phototherapy, which is much more effective than conventional UV irradiation of the skin.

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Preparation

PUVA therapy, despite its apparent harmlessness, is still a serious procedure that requires certain preparation. First, it is necessary not only to establish an accurate diagnosis, but also to determine the severity of the disease, which will determine the method of performing the procedure (or its type), the number of procedures, the type of psoralens used, the dose of radiation and photoactive drugs.

Let's consider what types of PUVA procedures there are and in what cases they are used.

The systemic type of procedure is considered the most common. It can be successfully used both for localized mild forms of pathologies and for diseases of moderate and severe severity, when the disease affects large areas of the body. Photosensitizers are taken in the form of tablets (often with low-fat food or milk). This should be done in advance. Irradiation is carried out 2-3 hours after taking the drugs.

A local procedure is performed if there are separate lesions on the skin and their total area is less than 20%. In this case, psoralens (solutions, ointments, emulsions) are applied locally to the affected areas, after which they are exposed to dosed radiation.

PUVA baths are a type of procedure that combines local application of drugs and a systemic approach to treatment. The patient is immersed in a bath with water in which psoralen is dissolved. UV irradiation is carried out a quarter of an hour after taking the bath.

Based on the diagnosis and the degree of skin damage, the doctor prescribes one or another type of PUVA therapy or a combination of systemic and local forms. In the second case, systemic therapy is prescribed first, and then local.

Photosensitizing drugs can also be prescribed in two types: synthetic and natural. The most popular drugs in PUVA therapy are: "Methoxalen", "Aminofurin", "Oxoralen", "Psoberan", "Trimethylpsoralen", etc. Depending on the type of procedure performed, drugs of the corresponding release form are prescribed.

Even before the preparation for the procedure, you need to inform the doctor about all the medications the patient is taking, because many drugs have such a side effect as increased photosensitivity of the skin. If this point is not taken into account, it is very difficult to avoid the development of side effects of the procedure.

In preparation for the PUVA procedure itself, patients are advised to take a shower the day before. To reduce the intensity of possible side effects, doctors sometimes prescribe vitamin A preparations (retinoids) and medications to improve liver function.

With systemic PUVA therapy, there is a need to protect certain parts of the body from UV radiation (lips, eyes, genital area in men, mammary gland area in women, etc.). For this purpose, sunscreens, special glasses and coatings are used.

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Technique PUVA therapy

The technique for performing the procedure will differ slightly depending on the type of PUVA therapy.

The systemic procedure involves taking psoralens orally 2-3 hours before the start of irradiation. The patient's entire body is irradiated. The duration of the procedure can vary from 3 to 20 minutes. They start with the minimum time, gradually increasing it towards the end of the therapeutic course.

The number of necessary procedures and the dose of psoralens are prescribed by the doctor, having studied the patients' condition and drug tolerance. The procedures are recommended to be performed once every 3 days.

Thus, during the local procedure, psoralens in the form of liquids and ointments are applied only to the areas of skin damaged by the disease. These same areas are exposed to ultraviolet rays after about 35-40 minutes, when the medicine is well absorbed into the skin.

The duration of the procedure and the dosage of photosensitizers in this case are determined by the doctor and depend on the skin disease and its severity. The therapeutic course of local PUVA therapy in most cases is limited to 10-20 procedures.

Such treatment is recommended to be carried out no more than 1-2 times a year depending on the radiation dose used and the severity of the disease. The total number of sessions for the entire period of the disease should be limited to 200.

PUVA therapy with psoralen baths is effective when the patient's body does not respond well to oral administration of psoralens. Skin diseases in children can be treated in the same way. Moreover, the effectiveness of this procedure is higher than that of local or systemic PUVA therapy.

Before starting the procedure, about 50 mg of the photosensitizing drug "Metaxalen" or 75-125 ml of "Ammifurin" are dissolved in the bath. The person is in such a bath for about 15 minutes, after which he is irradiated with UV rays. Usually, 15 to 40 such procedures are prescribed.

The dose of UV radiation can be low (10 to 20 J per 1 cm2 ⁾, medium (50 to 60 J per 1 cm2 ⁾ and high (130 J per 1 cm2 ⁾. Usually, doctors tend to use the lowest possible dose of radiation and begin therapy with minimal doses of 1.5-2 J per 1 ^cm2.

Phototherapy is recommended to be performed in medical institutions with specially equipped treatment rooms and devices for PUVA therapy. For local procedures, compact lamps-emitters are used, and for systemic PUVA therapy, cabins made like solariums are used, where the patient can receive a dose of radiation in a standing or lying position.

The PUVA therapy booth should be equipped with quartz, fluorescent, erythema and arc bactericidal lamps. A computer connected to it keeps track of each session (date, time of irradiation and its dose). Some devices are equipped with a system that sorts the data for each patient.

PUVA therapy at home

There is nothing unusual in the fact that some physiotherapy procedures can be carried out not in a clinic, but at home. But this does not mean that they should be prescribed to yourself, randomly determining the duration of the procedure, the type and doses of the materials used.

Any questions regarding any physical procedure performed at home must be discussed with the attending physician. Especially if these are questions about radiation dosage and the drugs used. High-dose irradiation does not pass without a trace, and only a specialist can calculate the minimum effective dose. In addition, the intensity and time of irradiation vary from procedure to procedure, which must also be taken into account and adhered to when performing the procedure independently.

At home, local PUVA therapy is mainly carried out. For this, special compact devices are used: ultraviolet lamps and a UV comb. The latter is designed to have a therapeutic effect on the scalp affected by the disease.

For systemic impact on large areas of the body affected by the disease, it is permissible to use a solarium. True, first you need to clarify the type of device used and the range of waves. But again, you should first discuss this treatment option with your doctor and follow his recommendations regarding the dose of radiation and psoralens used, as well as the time of exposure of the body to UV rays.

It would seem that everything is clear and quite safe, but most doctors are still against conducting PUVA therapy at home. This is explained by the fact that there is no control over the implementation of prescriptions and the patient's condition during the procedure. And the patient is tempted to try to speed up the cure by independently adjusting the doctor's prescriptions: by increasing the number of procedures, the dose of psoralens or UV rays.

Contraindications to the procedure

PUVA therapy is considered a relatively safe procedure when performed professionally. However, this does not mean that this method of phototherapy has absolutely no contraindications.

Firstly, photosensitizers are drugs, the introduction of which the patient's body can react to in different ways. If intolerance reactions concern a specific drug, it can be replaced with another. If the body reacts negatively to the group of drugs with a photosensitizing effect, it will be necessary to look for other ways to combat the disease.

Sometimes the problem is solved by simply replacing the systemic PUVA therapy with a local or PUVA bath, which does not require oral administration of psoralens.

This procedure is not used in cases of increased sensitivity to ultraviolet radiation, as well as in cases of increased photosensitivity of the body due to certain pathologies (albinism, xeroderma pigmentosum, porphyria, a large number of melanoma-risk moles on the body, etc.).

PUVA therapy is not prescribed for malignant melanoma, so as not to provoke tumor growth, and aphakia due to possible damage to the retina in the absence of a lens.

Pregnancy and breastfeeding are also considered contraindications to PUVA therapy.

The possibilities of using different types of PUVA therapy for the treatment of children with skin pathologies are considered in each specific case by the attending physician.

It is necessary to approach PUVA therapy with caution in fair-skinned patients, in patients with low immunity, in case of cataracts, uremia and renal failure, liver diseases. The question of the possibility of conducting UV irradiation sessions also arises acutely in patients who have previously undergone a course of exposure to ionizing radiation, as well as in patients with various oncological diseases.

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Consequences after the procedure

With the correct calculation of the psoralens dose and adequate implementation of the PUVA radiation procedure, the risk of negative consequences during or after the course of treatment is minimal. Some side effects that occur during the course are considered normal and disappear in a short time. Remote consequences that make themselves known after decades are more likely to be associated with numerous repeated courses of radiation.

Thus, the side effects observed during the course of treatment may differ depending on the form in which psoralens are used. Oral administration of photosensitizing drugs is associated with the risk of nausea, vomiting and stomach pain. Such symptoms are observed in 10-20% of patients.

The appearance of allergic reactions in the form of itching and skin rashes most often require a revision of the prescription. In some cases, patients complain of headaches, worsening sleep, insomnia, dizziness, anxiety, fatigue, increased blood pressure. All such adverse effects must be reported to the doctor.

Local application of psoralens can cause dryness of the skin, itching of the skin. Sometimes the development of contact or allergic dermatitis is noted.

Some unpleasant symptoms can also be associated with UV radiation itself. This includes the appearance of hyperemic areas of the skin, dark spots, and even burns in the case of sensitive skin or a large dose of radiation.

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Complications after the procedure

More severe complications can be observed several years after PUVA therapy if the irradiation procedures were carried out repeatedly with courses repeated 2 or more times. Some patients developed such dangerous pathologies as cataracts and skin cancer (squamous cell and basal forms, melanoma). Premature photoaging of the skin was also observed as a result of its active absorption of UV rays (the appearance of early wrinkles, age spots, deterioration of the appearance of the skin).

By the way, as far as oncology is concerned, the connection between dosed UV radiation and cancer development has not been definitively confirmed. Many scientists have tried to establish the relationship between the appearance of tumors and long-wave radiation through experiments, but everything has remained at the hypothesis level.

Some side effects can be avoided if you approach the treatment process itself wisely. For example, doctors recommend taking oral medications from the psoralens group with fatty foods, or at least with milk rather than water, to reduce the negative impact on the gastrointestinal tract. Milk and cereal dishes help effectively combat nausea. The gag reflex can be prevented by dividing (and in severe cases, reducing) the dose of the drug or taking antiemetics (for example, Metoclopromide).

Skin burning in the area exposed to radiation and its dryness are observed 2-3 days after the start of therapy. These unpleasant symptoms can be relieved with the help of softening and moisturizing creams.

The appearance of multiple pronounced unpleasant symptoms indicates that the PUVA therapy procedure was performed incorrectly. The patient's condition may worsen due to an incorrectly selected dose of radiation and photosensitizer, high frequency and duration of procedures, which is often observed in the case of PUVA therapy performed at home.

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Care after the procedure

As with any light therapy procedure, special care is required for the skin after PUVA therapy. Firstly, to prevent drying and burning of the skin in the area of exposure to UV rays, after consulting a doctor, it is recommended to use care creams with a soothing, softening and moisturizing effect. Antihistamines can be used to relieve itching.

Secondly, the skin must be protected from natural radiation (sunlight), as there is a high risk of sunburn. To prevent this, it is recommended to use sunscreens with a good filter and closed clothing outdoors in clear weather.

During the day after the procedure, it is necessary to protect not only the skin, but also the eyes from the sun. Wearing quality sunglasses will help to avoid clouding of the lens of the eye (cataracts).

Since long-term treatment with PUVA therapy may in some way contribute to the development of skin cancer, it is necessary to undergo preventive examinations by a dermatologist in order to detect possible pathological changes in time. Annual consultations with an ophthalmologist are also mandatory.

If unusual symptoms appear, it is recommended to consult a doctor without waiting for the end of the course of treatment. Consultation and assistance of a doctor may be necessary:

• in case of severe burns on the skin and pain,
• if the skin around the affected area becomes very red and there is some strange discharge on it,
• when signs of intoxication of the body appear, manifested in the form of fever, chills, nausea, headaches, etc.
• if side effects are severe or persist for a long time.

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Reviews of PUVA therapy

Many patients who have undergone treatment with PUVA therapy speak only positively about the procedure. Take, for example, psoriasis, for which PUVA therapy is one of the most effective methods of combating the disease, allowing for long-term remission and improving the quality of life of patients.

The effectiveness of the method for most mild and moderate pathologies is about 85%. Even in cases of advanced disease, a fifth of patients note a significant improvement in the condition of the skin.

Knowing how difficult it is to fight such pathologies as psoriasis, vitiligo, alopecia, etc., and how much time it takes to reduce the manifestations of the disease, patients and doctors note the rapid and long-lasting effect of phototherapy using psoralens. After only 5-8 procedures, patients notice the positive effects of PUVA therapy, and after completing the full course of treatment, they can forget about the disease for a long period (2 years or more). This is immeasurably important for a person suffering from an incurable disease that negatively affects the patient's well-being, attitudes of others, and self-esteem.

Another important feature of the PUVA therapy method is that it is not addictive, which means that repeated courses remain no less effective than the first ones. This is very important for the treatment of severe forms of practically incurable pathologies.

There is also the possibility of carrying out preventive treatment to help prevent exacerbation of the disease.

It is also worth noting the convenience of using the technique, which is available both in inpatient and outpatient settings with the possibility of performing procedures even at home.

A small number of contraindications and good tolerability of PUVA therapy make it possible for many people to receive quality treatment. However, the price is quite high and not everyone can afford it.

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