with a new and unfamiliar physician at every turn. As members of a serving profession we must look beyond our individual and collective interests to examine the specific characteristics of clinical care that will serve patients best. In a way all physicians are specialists. But whether the specialty is general practice or a more restricted field, no physician who gives clinical care can be exempted from assuming

the scientific and humanitarian responsibilities of the profession in equal measure. As long as this balance is established and maintained, increasing specialization will present no threat to any patient - or to any physician. RICHARD B. GOLDBLOOM, MD

Professor and head Department of pediatrics Daihousie University Halifax, NS

PUVA photochemotherapy Psoralens and ultraviolet light have been used in the treatment of cutaneous disease since the beginnings of recorded history. The seeds of the plant Psoralea corylifolia, a member of the pea family, are described in the "Ebers Papyrus" (circa 1550 BC) for the treatment of vitiligo.1 Even today in India peasants treat vitiligo much the same as they did in 1400 BC, as described in the "Atherva Veda".1 The seeds are soaked in water overnight; in the morning the water is drunk, and a paste made from the seeds is applied to the vitiliginous areas. The patient then sits in strong sunlight. As early as the 13th century AD powdered seeds of the plant Ammi majus, a weed found abundantly in the Nile River Valley, were described as being used to treat vitiligo.1 The fruits of P. corylifolia, A. majus and many other plants, including lime, lemon, fig, parsley, parsnip and clove, have been shown to contain psoralens, which are photoactive furocoumarin compounds. Extracted from the powdered fruits of A. majus is the crystalline compound 8-methoxypsoralen. It has been known for many years that ultraviolet light is beneficial in the treatment of psoriasis. Current terminology has divided the ultraviolet portion of the electromagnetic spectrum into UVA (long wavelength: 320 to 400 nm, peak emission 365 nm); UVB (middle wavelength: 290 to 320 nm), the sunburn region; and UVC (short wavelength: 100 to 290 nm), the germicidal region. It has been shown that the portion of the spectrum activating psoralens in the skin is the UVA re-

gion, and that a psoralen and UVA together inhibit deoxyribonucleic acid (DNA) synthesis.2 Increased proliferation of epithelial cells is characteristic of psoriasis. Therefore, the hypothesis that treatment with a psoralen and ultraviolet light will result in improvement in patients with psoriasis by inhibiting DNA synthesis is logical. The combination of oral administration of a psoralen (P) and UVA irradiation has become commonly known as PUVA therapy. The final development that made PUVA therapy possible was the manufacture of PUVA units capable of emitting high-intensity UVA. The earliest clinical trials of 8methoxypsoralen treatment were carried out by El Mofty"4 in Egypt. These studies demonstrated clearly the efficacy of 8-methoxypsoralen and ultraviolet light in the treatment of vitiligo. Clinical trials during 1972 and 1973 of UVA irradiation and topical application of 8-methoxypsoralen for psoriasis were encouraging.5'6 Since 1974 several continuing cooperative studies of 8-methoxypsoralen given orally and UVA irradiation have been carried out in Europe and North America. Initially these studies were preoccupied primarily with establishing safe, effective treatment schedules. This having been accomplished, the purpose of these studies seems to have changed in the past year to a continuing assessment of the frequency of side effects from long-term exposure to PUVA. The dramatic improvement in patients with even the most severe

1348 CMA JOURNAL/JUNE 10, 1978/VOL. 118

Myeostatiii Vaginal Cream plus Oral Tablets

Aniost effective waytotreat recun.nt vaginal c*uwlidiasis. MYCOSTATIN VAGINAL CREAM MYCOSTATIN VAGINAL TABLETS indicatIons: Vaginal infections caused by Candida (Monilia) species. Dosage: Cream: Usual dosage is 4 g (100,000 units) once or twice daily. Tablets: Usual dosage is 1 tablet (100,000 units) once or twice daily. In most cases 2 weeks of therapy will be sufficient but in some cases more prolonged treatment may be necessary. Administration should be continued for at least 48 hours after clinical cure to prevent relapse. Instructions for the patient are enclosed in each package. Supply: Cream: Tubes 01120 g with applicator designed to deliver a 4 g dose. Each gram contains 25,000 units of nystatin in a cream base. Tablets: Packages of 15 and 30 tablets with applicator. Each tablet contains 100,000 units of nystatin and 0.95 g of lactose.

MYCOSTATIN ORAL TABLETS IndIcatIons: Prevention and treatment of infection caused by Candida (Monilia) species in the intestinal tract and for protection against candidal overgrowth during antimicrobial or corticosteroid therapy. Dosage: Usual prophylactic and therapeutic dose is 1 tablet (500,000 units) 3 times daily. Administration should be continued for at least 48 hours after clinical cure to prevent relapse. Supply: Bottles of 100 tablets of 500,000 units per tablet.

ALL DOSAGE FORMS ContraIndIcatIon: Hypersensitivity to nystatin. Precaution: Use of the vaginal applicator may not be considered desirable during pregnancy. Adverse ReactIons: Mycostatin is virtually nonsensitizing and nontoxic and is well tolerated, even on prolonged administration. Large oral doses may produce diarrhea and GI. distress. If irritation or hypersensitivity should occur following intravaginal or topical use, discontinue medication. Product Monograph available to physicians and pharmacists on request.

SQUiBB Squibb Qualiir-ihe Priceless Ingredient ER SQUIBB & SONS ITO MONTREAL, .2365 COTE DE QUE LIESSE.

psoriasis given PUVA therapy has resulted in a proliferation of PUVA treatment centres in Europe and the United States. Four such centres exist in Canada - two in Toronto, one in Calgary and one in Vancouver. The experience of Wasserman and colleagues, as reported in this issue of the Journal (page 1379), is in agreement with the reported findings of other studies.7" Their report represents the first independently published Canadian study. Physicians throughout Canada will look forward

to further reports on the long-term to treatment protocol are necessary side effects detected at this and other for safe and effective PUVA therapy. PUVA centres. Because of the uniformly good results A standard effective PUVA treat- obtained with PUVA therapy this ment schedule has more or less been modality should be made available to established. More PUVA treatment patients with extensive psoriasis recentres will be required if adequate fractory to the usual treatment mofacilities are to be available for pa- dalities. These patients, however, tients most severely affected by pso- must be made fully aware of the riasis. Initially treatment facilities potential side effects of long-term should best be associated with major therapy regardless of how remote referral centres where therapists ex- they may seem. perienced in PUVA are available. BERNARD J. BENDL, MD, FRCP[C] Strict documentation and adherence 3195 Granville St., Ste. 206 Vancouver, BC

References

L.4.K MARGITSZIGET BUDAPEST An island on the road to world fame, an island in the heart of a metropolis, an island far from the busy hum of the city:

MARGARET*ISLAN D BUDAPEST HUNGARY Margaret-island needs no introduction. Nature endowed it with health-giving thermal springs in a beautiful setting. We have now built a new Thermal Hotel on this island.

1. FITZPATRICK TB, PATHAK MA: His-

torical aspects of methoxsalen and other furocoumarins. J Invest Dermatol 32: 229, 1959 2. PATHAK MA, FITZPATRICK TB: Rela-

tionship of molecular configuration to the activity of furocoumarins which increase the cutaneous responses following long wave ultraviolet radiation. Ibid, p 255 3. EL MOFTY AM: A preliminary clinical report on the treatment of leucodermia with Ammi majus linn. Egypt Med Assoc J 31: 651, 1948 4. Idem: Further study on treatment of leucodermia with Ammi majus linn. Egypt Med Assoc J 35: 1, 1952 5. TRONNIER H, SCHULE D: First results

of therapy with longwave UV after photosensitization of skin (abstr), Presented at Sixth International Congress of Photobiology, Bochum, West Germany, Aug 1972 6. WALTER JF, VOORHEES JJ: Psoriasis

Welcomes those who are in search of a cure, coupled with entertainment and relaxation, those who long for the stillness of nature as well as the hum of a metropolis. - pools filled with thermal waters of 34, 36 and 400C, - diagnostic, X-ray, laboratory, ECG, and dental departments, - hydrotherapy, balneotherapy, various drinking and breathing cures, - underwater exercises, massage, effervescent baths, shower and mudbaths, dental waterjets, electro- and mechanotherapies. The medicinal waters and medical treatments bring remarkable results in curing locomotor disorders, bone, articular, muscular diseases, nervous complaints, respiratory and circulatory disturbances. The hotel has 206 rooms with bath, international, Hungarian, and dietary cuisine, night-club, sun-terrace, swimming pool, sauna and solarium. The Islands calm atmosphere, its air and beautiful woodlands enhance the beneficial results of the medicinal waters and treatments. Opening: the 1st of April, 1979.

-U

.NUUSH.

Danubius Hotel and Spa Company H*1138 Budapest, Margitsziget Phone 111.000, Telex 22-6850 1350

GMA JOURNAL/JUNE 10, 1978/VOL. 118

improved by psoralen plus black light. Acta Dermatol Venereol (Stockh) 53: 469, 1973 7. PARRISH JA, FITZPATRICK TB, TANEN-

BAUM L, et al: Photochemotherapy of psoriasis with oral methoxsalen and longwave ultraviolet light. N Engi J Med 291: 1207, 1974 8. WOLFF K, FITzPATRICK TB, PARRISH

JA, et al: Photochemotherapy for psoriasis with orally administered methoxsalen. Arch Dermatol 112: 943, 1976 9. LAKSHMIPATHI T, GOULD PW, MACKENZIE LA, et al: Photochemotherapy in the treatment of psoriasis. Br J

Dermatol 96: 587, 1977 10. WEISMANN K, HOWITZ J, BRO-J0RGEN-

SEN A: Treatment of resistant psoriasis with oral 8-methoxypsoralen and longwave ultraviolet light (PUVA). Treatment schedule and a follow-up study. Acta Dermatol Venereol (Stockh) 57: 73, 1977 11. MELSKI JW, TANENBAUM L, PARRISH JA, et al: Oral methoxsalen photochemotherapy for the treatment of

psoriasis: a cooperative clinical trial. J invest Dermatol 68: 328, 1977

PUVA photochemotherapy.

with a new and unfamiliar physician at every turn. As members of a serving profession we must look beyond our individual and collective interests to e...
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