Clinical and E.xperimental Dermalology 1492; 17: 65 W).
Onycholysis in a case of atopic eczema treated with PUVA photochemotherapy J.M.MORGAN, R.WELLER AND S.J.ADAMS Department of Dermatology, Carter Bequest Hospital, (Cambridge Road, Middlcsbrtmgh, Cleveland TS5 5NH, UK .•\ccepted for publication 13 May 1991
Summary
occasional relapses of eczema. Four months after starting Onycholysis following the in^estion of psoralens and PUVA photochemotherapy his eczema was quiescent and subsequent exposure to natural sunlight has been his hair was growing well. He had developed painful reported on several occasions'-^ and was first reported onycholysis of all 10fingernails(Fig. 1) and the nails of his following photochemotherapy in 1978 by Ortonne and right great toe. The total cumulative dose of UVA at this Haran from I'rancc' and in 1979 by IVlackie from time was 114-5 J. He was clinically and biochemically Scotland.•* Mackie commented that she hoped to stimu- euthyroid and was taking no oral medication other than 8late further reports of onycholysis induced by PUVA methoxypsoralen. In particular, he had taken no tetraphotochemotherapy in order to establish whether or not it cyclines. Mycological examination and culture of fingerwas a definite complication of such treatment. Since then, nail clippings was negative. Maintenance treatment was continued once a week with 30 mg S-methoxypsoralen there has been a dearth of similar reports. followed by reduced UVA exposure (3 J). He was given We describe a patient with severe atopic cc/.cma and cotton gloves to wear during treatment and his nails had alopecia totalis who developed onycholysis of all Hnger regrown normally within three months. nails and a toe nail during PUVA photochemotherapy. Case report
Discussion
CSB is a 2()-year-old man with a 17-ycar history of eczema which had been particularly troublesome for 18 months before presentation. Treatment with topical corticosteroids, emollients and oral antihistamines had been unsuccessful. In addition, he suffered from asthma and gave a 6-month history o) alopecia. On examination, he had widespread, excoriated and lichcnified eezema. He had normal fingernails and alopecia totalis. He was admitted for in-patient management. Treatment with potent topical corticosteroids and oral antibiotics failed to control his condition adequately and in view of his dual pathology he was started on PUVA photochemotherapy. He was fair skinned, but able to tan (skin type II). He was given 30 mg 8-methoxypsoralen {0-5 mg/kg) orally 2 h before UVA exposure, which was started at 0-5 J three times weekly and increased by 0-5 J each week to a maximum of 4 J. Six weeks after starting treatment, his eczema was settling and his scalp hair had begun to grow. His PUVA photochemotherapy was reduced to twice weekly. He continued under regular review and suffered
Photo-onycholysis has been recorded as a result of exposure to intense sunlight alone^'' and frequently as a response to drugs (including psoralens) and sunlight,'-' but it has been reported only a few times in association with psoralens and UV.A.''^ Parker and Diffcy'* have shctwn that normal human nails allow transmission of decreasing amounts of optical radiation as the wave length shortens; i.e. \isible light (400-800 nm) is well transmitted while UVB (280-320 nm) is effectively screened out. Some UVA (320-400 nm) is transmitted at the longer end of its spectrum and transmission of as much as 50",, could theoretically be transmitted through thin nails.'* It is therefore logical to expect some cases of onycholysis induced by PUVA photochemotherapy, as psoralens photo-sensitize to wave lengths 340-360 nm. The earlier reports of onycholysis associated with photochemotherapy were in patients with \itiligo or mycosis fungoides.''' This is the first report of a patient with eczema developing onycholysis as a result of PUVA photochemotherapy. In the intervening years, the use of PUVA photochemotherapy for psoriasis has increased greatly, and has been used at much higher doses and for longer periods than in our patient. It is therefore very surprising to find no reports of onycholysis following PUVA photochemotherapy for psoriasis.
(.orrespondcnee: Dr S.J.Adams, Department of Dermatology, (barter Dequest Hospital, (Cambridge Road, Middlesbrough, Cleveland. TS5 5NI!, UK.
65
66
J.M.MORGAN, R.WELLER AND S.J.ADAMS
l-'igure 1. Onycholysis o! patient's
nails at the rime when he first complained of discomfort.
There are three possible explanations for the lack of such reports in psoriatic patients: (a) photo-onycholysis may have been observed in psoriatic patients, but not reported; (b) it might be difficult to di.stinguish psoriatic nail changes from photo-onycholysis, though the latter is often painful and usually affects all nails simultaneously; (c) psoriatic nails provide a more efficient barrier to UVA than normal nails. The last explanation is supported by the work of Baran and Juhlin' who showed that much less UVA penetrated psoriatic nails than normal nails, even when they were the same thickness. The authors do not give details of the number of nails tested nor do they describe changes in colour or texture (if any) in the psoriatic nails, but their w ork suggests that psoriatic nails arc particularly resistant to photo-onycholysis. As PUVA photochemotherapy is now being used increasingly to treat severe atopic eczema the side effect of onycholysis may become more frequent and dermatolo-
gists may need to warn patients to screen their nails in order to prevent the development of this uncomfortable condition. References 1. /ala L, Omar A, Krebs A. Photo-onycholysis induced by 8Methoxypsoralen. Dermatologica 1977; 154: 203-215. 2. Rau RC, Flowers FP, Barrett JL. Photo-onycholysis secondary to psoralen use. Letter in .-irehives of Dermatology 1978; 114: 44H. 3. Ortonne J-P, Baran R. Photo-onycholyse induite par la photochjmiotherapie orale. Annals Dermatologie I'enereologie 1978; 105: 887-888. 4. Mackie RM. Onycholysis occurring during PUVA therapy. Clinical and Experimental Dermatology 197^; 4: 111-113. 5. I.ogan RA, Hawk JLM. Spontaneous photo-onycholysis- British Journal of Dermatology 1985; 113: 605 610. 6. Parodi A, Guarrera M, Rebora A, Spontaneous photo-onycholysis. Photo-dermatology 19S7 4: 160-161. 7. Baran R, Juhlin L. Drug induced photo-onychoKsis. Journal of the Ameriean .Academy of Dermatology 1M87; 17: 1012 1016. 8. Parker SG, Diffey B.L. The transmission of optical radiation through human nails. British Journal oJ Dermalology 1983; 108: 11 16.
Onycholysis in a case of atopic eczema treated with PUVA photochemotherapy J.M.MORGAN, R.WELLER AND S.J.ADAMS Department of Dermatology, Carter Bequest Hospital, (Cambridge Road, Middlcsbrtmgh, Cleveland TS5 5NH, UK .•\ccepted for publication 13 May 1991
Summary
occasional relapses of eczema. Four months after starting Onycholysis following the in^estion of psoralens and PUVA photochemotherapy his eczema was quiescent and subsequent exposure to natural sunlight has been his hair was growing well. He had developed painful reported on several occasions'-^ and was first reported onycholysis of all 10fingernails(Fig. 1) and the nails of his following photochemotherapy in 1978 by Ortonne and right great toe. The total cumulative dose of UVA at this Haran from I'rancc' and in 1979 by IVlackie from time was 114-5 J. He was clinically and biochemically Scotland.•* Mackie commented that she hoped to stimu- euthyroid and was taking no oral medication other than 8late further reports of onycholysis induced by PUVA methoxypsoralen. In particular, he had taken no tetraphotochemotherapy in order to establish whether or not it cyclines. Mycological examination and culture of fingerwas a definite complication of such treatment. Since then, nail clippings was negative. Maintenance treatment was continued once a week with 30 mg S-methoxypsoralen there has been a dearth of similar reports. followed by reduced UVA exposure (3 J). He was given We describe a patient with severe atopic cc/.cma and cotton gloves to wear during treatment and his nails had alopecia totalis who developed onycholysis of all Hnger regrown normally within three months. nails and a toe nail during PUVA photochemotherapy. Case report
Discussion
CSB is a 2()-year-old man with a 17-ycar history of eczema which had been particularly troublesome for 18 months before presentation. Treatment with topical corticosteroids, emollients and oral antihistamines had been unsuccessful. In addition, he suffered from asthma and gave a 6-month history o) alopecia. On examination, he had widespread, excoriated and lichcnified eezema. He had normal fingernails and alopecia totalis. He was admitted for in-patient management. Treatment with potent topical corticosteroids and oral antibiotics failed to control his condition adequately and in view of his dual pathology he was started on PUVA photochemotherapy. He was fair skinned, but able to tan (skin type II). He was given 30 mg 8-methoxypsoralen {0-5 mg/kg) orally 2 h before UVA exposure, which was started at 0-5 J three times weekly and increased by 0-5 J each week to a maximum of 4 J. Six weeks after starting treatment, his eczema was settling and his scalp hair had begun to grow. His PUVA photochemotherapy was reduced to twice weekly. He continued under regular review and suffered
Photo-onycholysis has been recorded as a result of exposure to intense sunlight alone^'' and frequently as a response to drugs (including psoralens) and sunlight,'-' but it has been reported only a few times in association with psoralens and UV.A.''^ Parker and Diffcy'* have shctwn that normal human nails allow transmission of decreasing amounts of optical radiation as the wave length shortens; i.e. \isible light (400-800 nm) is well transmitted while UVB (280-320 nm) is effectively screened out. Some UVA (320-400 nm) is transmitted at the longer end of its spectrum and transmission of as much as 50",, could theoretically be transmitted through thin nails.'* It is therefore logical to expect some cases of onycholysis induced by PUVA photochemotherapy, as psoralens photo-sensitize to wave lengths 340-360 nm. The earlier reports of onycholysis associated with photochemotherapy were in patients with \itiligo or mycosis fungoides.''' This is the first report of a patient with eczema developing onycholysis as a result of PUVA photochemotherapy. In the intervening years, the use of PUVA photochemotherapy for psoriasis has increased greatly, and has been used at much higher doses and for longer periods than in our patient. It is therefore very surprising to find no reports of onycholysis following PUVA photochemotherapy for psoriasis.
(.orrespondcnee: Dr S.J.Adams, Department of Dermatology, (barter Dequest Hospital, (Cambridge Road, Middlesbrough, Cleveland. TS5 5NI!, UK.
65
66
J.M.MORGAN, R.WELLER AND S.J.ADAMS
l-'igure 1. Onycholysis o! patient's
nails at the rime when he first complained of discomfort.
There are three possible explanations for the lack of such reports in psoriatic patients: (a) photo-onycholysis may have been observed in psoriatic patients, but not reported; (b) it might be difficult to di.stinguish psoriatic nail changes from photo-onycholysis, though the latter is often painful and usually affects all nails simultaneously; (c) psoriatic nails provide a more efficient barrier to UVA than normal nails. The last explanation is supported by the work of Baran and Juhlin' who showed that much less UVA penetrated psoriatic nails than normal nails, even when they were the same thickness. The authors do not give details of the number of nails tested nor do they describe changes in colour or texture (if any) in the psoriatic nails, but their w ork suggests that psoriatic nails arc particularly resistant to photo-onycholysis. As PUVA photochemotherapy is now being used increasingly to treat severe atopic eczema the side effect of onycholysis may become more frequent and dermatolo-
gists may need to warn patients to screen their nails in order to prevent the development of this uncomfortable condition. References 1. /ala L, Omar A, Krebs A. Photo-onycholysis induced by 8Methoxypsoralen. Dermatologica 1977; 154: 203-215. 2. Rau RC, Flowers FP, Barrett JL. Photo-onycholysis secondary to psoralen use. Letter in .-irehives of Dermatology 1978; 114: 44H. 3. Ortonne J-P, Baran R. Photo-onycholyse induite par la photochjmiotherapie orale. Annals Dermatologie I'enereologie 1978; 105: 887-888. 4. Mackie RM. Onycholysis occurring during PUVA therapy. Clinical and Experimental Dermatology 197^; 4: 111-113. 5. I.ogan RA, Hawk JLM. Spontaneous photo-onycholysis- British Journal of Dermatology 1985; 113: 605 610. 6. Parodi A, Guarrera M, Rebora A, Spontaneous photo-onycholysis. Photo-dermatology 19S7 4: 160-161. 7. Baran R, Juhlin L. Drug induced photo-onychoKsis. Journal of the Ameriean .Academy of Dermatology 1M87; 17: 1012 1016. 8. Parker SG, Diffey B.L. The transmission of optical radiation through human nails. British Journal oJ Dermalology 1983; 108: 11 16.
