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Photochemotherapy (PUVA)
General information
Photochemotherapy, which consists of oral (and sometimes topical) administration of psoralens (the furocoumarins 5-methoxypsoralen, 8-methoxypsoralen, and trioxysalen) plus long-wave ultraviolet radiation, known as PUVA, is a well-established effective treatment for psoriasis, which has also been used for vitiligo [ ], mycosis fungoides, alopecia areata, dyshidrotic eczema, atopic dermatitis, and certain other skin diseases. Guidelines for treatment have been recommended [ , ].
Bathwater delivery of psoralens (“Bath PUVA”) is an attractive alternative to oral administration, since it virtually lacks systemic adverse effects and the rapid decline of photosensitivity after bath PUVA enables the patient to pursue daily activities without restrictions [ ]. Trioxysalen bath PUVA does not have carcinogenic effects [ ].
Guidelines for topical PUVA therapy, including bath and local immersion PUVA therapy, have been published by the British Photodermatology Group [ ].
Short-term reactions are not uncommon. They include erythema, burns, nausea, pruritus, headache, and dizziness. Hypersensitivity reactions, which are uncommon, include drug fever, skin rashes, and bronchial asthma. Long-term treatment increases the risk of non-melanoma skin cancers and possibly of cutaneous melanoma.
Organs and systems
Cardiovascular
A rise in ambient temperature can have cardiovascular effects. In high-risk conditions, cardiovascular monitoring during treatment has been advised [ ], although patients with cardiovascular disease and hypertension are also reported to tolerate PUVA therapy without evidence of cardiovascular stress [ ]. Edema of the legs has been noted occasionally.
Respiratory
Bronchial asthma and coughing attacks have been attributed to methoxypsoralen allergy [ ].
Nervous system
Dizziness, headache, and itching are well-known immediate adverse effects [ ]. Persistent skin pain can be serious [ ].
Sensory systems
Although several cases of cataracts presumably or probably induced by PUVA have been reported [ , ], the risk appears to be small when recommendations to prevent ocular complications [ ] are strictly adhered to [ ].
Other ocular symptoms after PUVA include photophobia, conjunctivitis, keratitis, and dry eyes [ ]. Adequately protecting the eyes from the sun reduces the risk of acute toxic effects on the cornea and conjunctivae [ ].
Visual field defects have been described in some patients [ ].
In a study of the effect on the corneal endothelium of exposure of a light-adjustable intraocular lens to ultraviolet light in 10 patients, there was no additional endothelial damage compared with that normally expected after phacoemulsification [ ].
Metabolism
Severe hyperlipidemia possibly related to PUVA has been observed once [ ].
Hematologic
There have been reports of acute leukemia [ ] and neutropenia [ ] during PUVA and one dubious report of preleukemia [ ]. Transformation of stable chronic myelomonocytic leukemia to acute myeloid leukemia has been attributed to PUVA [ ]. These events may all have been purely coincidental and not causally related, as PUVA does not appear to increase the risk of non-cutaneous malignancies [ ].
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