Pharmacology and Therapeutics

PHOTOCHEMOTHERAPY (PUVA) AND PSORIASIS: COMPARISON OF 8-MOP AND 8-MOP/5-MOP A. LANGNER, M.D., H. WOLSKA, M.D., J. KOWALSKI, M.D,, H. DURALSKA, M.D., AND E. MURAWSKA, M.D. From the Department of Dermatology, Warsaw Medical Academy, Warsaw, Poland

ABSTRACT: Twenty-eight psoriatic patients received PUVA treatment (psoralen and long ultraviolet irradiations. Two preparations were used; 8-methoxypsoralen and a mixture of 5-methoxypsoralen and 8-methoxypsoralen. Both gave considerable improvement, but in 6 cases the lesions reappeared after 2 to 8 weeks, in spite of maintenance treatment. In this report, photochemotherapy of psoriasis was compared, using a UVA emitting lamp, 8-MOP, and a mixture of 8-MOP and 5-methoxypsorafen (5-MOP).'^7

Material and Methods Twenty-eight patients of both sexes with various duration and intensity of the disease were treated (Table 1). The lit^lTt source consisted of 48 fluorescent lamps giving a wall of light with dimensions 2.25 m by 1.25 m. The wavelength of ultraviolet radiation emitted by the lamps was 320-400 nm with maximum at 360-370 nm. Energy of radiation at a distance of 10 cm from the lamp was 2,500-3,500 /jw/cm=, declining with increasing distance from the center. Two drugs were compared for effectiveness: 8-MOP (10 mg capsules) and a mixture of 8-MOP and 5-MOP (20 mg tablets). Both were given in doses of 0.8-1.2 mg/kg body weight, 2 hours before irradiation applied to both sides of Address for reprints: Doz. Dr. A. Langner, Department of Dermatology, Warsaw Medical Academy, ul. Koszykowa 82 a, 02-008, Warsaw, Poland.

688

the body for periods of 10 to 20 minutes respectively. Depending on the erythematous reaction of hyperpigmentation, the dosage of irradiation was increased. The patients were treated 3 times a week until pronounced improvement was obtained, and then twice a week to complete regression of lesions, and finally once weekly. The only topical medication given during the treatment consisted of 5% salicylic acid ointment in petrolatum. Results The treatment results are presented in Table 1. Marked improvement (only slight acanthosis, mainly on the legs) or complete regression of the pathological changes were obtained after 12 irradiations on average. Rapid regression of skin lesions was noted in cases of extensive, almost generalized psoriasis with slight acanthosis. Rapid regression also occurred in patients with a strong erythematous reaction during photochemotherapy. Less responsive were patients with psoriasis with pronounced acanthosis (old psoriatic lesions). Nevertheless, even in these patients complete regression of lesions or marked improvement was achieved after somewhat longer courses of radiation therapy. No improvement was noticed in one patient with long-lasting psoriasis with extensive and pronounced acanthosis. In 2 patients with vitiligo coexisting with psoriasis, repigmentation was obtained quickly. In 2 patients with coexisting polymorphous light eruptions, changes characteristic of these lesions

No. 9

PUVA

•

Langner, et al.

689

Table 1. Comparison of the Therapeutic Activity of 8-MOP and 8-MOP and 5-MOP Results Regression of lesions Marked Improvement Regression of lesions and marked improvement

8-MOP

8-MOP and 5-MOP

Both drugs

Mean no. of irradiations % of patients Mean no. of irradiations % of patients

18 30%

9 55%

11,4

14 50%

13 17%

13 28%

Mean no. of irradiations % of patients

15 80%

10 72%

12 75%

appeared during the treatment, but of moderate intensity which did not make continuation of photochemotherapy impossible. Wtih progressing hyperpigmentation, these lesions became increasingly rare. Regression of lesions was somewhat faster when using 8-MOP and 5-MOP. Marked improvement or regression of lesions in patients treated with 8-MOP was observed after 15 irradiations on average, and in those treated with 8-MOP and 5-MOP after 10 (Table 1). In 4 patients, fresh eruption of psoriatic lesions during the treatment was observed, but these lesions quickly flattened and disappeared. Side effects such as general malaise, nausea and vomiting were noted in some patients, but seemed to be unrelated to the drug used. Hyperpigmentation of varying degrees and unif^orm distribution was observed in all cases. Discussion

In a majority of our patients, marked improvement or complete regression of lesions was obtained without resorting to topical treatment. Many patients treated with photochemotherapy had psoriasis of long standing, resistant to other methods of treatment. In 2 cases of erythroderma, toxic lesions due to previous treatment with dithranol and salicylic acid were noted, but the new method of treatment brought complete

46%

remission quickly. There was no significant difference in effectiveness of 8-MOP + 5-MOP and 8-MOP alone. Further observation did not substantiate the data of Wolff et al.-^ concerning the prevention of psoriasis relapses during the maintenance treatment. In six of our twenty eight patients in spite of once weekly PUVA-treatment, relapses were noted after two to eight weeks.

Drug Names methoxsalen: 8-MOP (8-methoxypsoralen) 8-MOP/5-MOP: Beroxan (U.S.S.R.)

References 1. Harber, L. C, Personal communication. 2. Weber, G., Combined 8-methoxypsoralen and black ligbt therapy of psoriasis. Br. J. Dermatol. 90:317, 1974. 3. Musajo, L., Rodighiero, C, and Dall'Acqua, F., Evidence of a photoreaction of the photosensitizing furocoumarins with DNA and with pyrimidine nucleosides and nucleotides. Experientia 21:24, 1965. 4. Parrish, J. A., Fitzpatrick, T. B., Tanenbaum, L., and Pathak, M. A., Photochemotherapy of psoriasis with oral methoxsalen and longwave ultraviolet light, N. Engl. J. Med. 291:1207, 1974. 5. Wolff, K., Parrish, J. A., Fitzpatrick, T. B., Cschnait, F., Gilchrest, B., Honigsmann, H., and Pathak, M. A., Photochemotherapy of psoriasis with oral psoralens. 1. Invest. Dermatol. 64:295, 1975. 6. Walter, ). F., Voorhes, j . J., Kelsey, W. H., and Duell, E. A., Psoralen plus black light inhibits epidermal DNA synthesis. Arch. Dermatol. 107:861, 1973. 7. Wolff, K., and Holubar, K., Phototoxische Reaktion auf 8-Methoxypsora!en. UltrasVrukturelle Veranderungen in der Epidermis. Arch. Klin. Exp. Dermatol. 237:477, 1970.