K.E. McKENNA

Guidelines for topical photodynamic therapy: report of a workshop of the British Photodermatology Group

Summary Topical photodynamic therapy (PDT) is effective in the treatment of certain non‐melanoma skin cancers and is under evaluation in other dermatoses. Its development has been enhanced by a low rate of adverse events and good cosmesis. 5‐Aminolaevulinic acid (ALA) is the main agent used, converted within cells into the photosensitizer protoporphyrin IX, with surface illumination then triggering the photodynamic reaction. Despite the relative simplicity of the technique, accurate dosimetry in PDT is complicated by multiple variables in drug formulation, delivery and duration of application, in addition to light‐specific parameters. Several non‐coherent and coherent light sources are effective in PDT. Optimal disease‐specific irradiance, wavelength and total dose characteristics have yet to be established, and are compounded by difficulties comparing light sources. The carcinogenic risk of ALA‐PDT appears to be low. Current evidence indicates topical PDT to be effective in actinic keratoses on the face and scalp, Bowens disease and superficial basal cell carcinomas (BCCs). PDT may prove advantageous where size, site or number of lesions limits the efficacy and/or acceptability of conventional therapies. Topical ALA‐PDT alone is a relatively poor option for both nodular BCCs and squamous cell carcinomas. Experience of the modality in other skin diseases remains limited; areas where there is potential benefit include viral warts, acne, psoriasis and cutaneous T‐cell lymphoma. A recent British Photodermatology Group workshop considered published evidence on topical PDT in order to establish guidelines to promote the efficacy and safety of this increasingly practised treatment modality.

Guidelines for topical photodynamic therapy: update.

Multicentre randomized controlled studies now demonstrate high efficacy of topical photodynamic therapy (PDT) for actinic keratoses, Bowen’s disease (BD) and superficial basal cell carcinoma (BCC), and efficacy in thin nodular BCC, while confirming the superiority of cosmetic outcome over standard therapies. Long‐term follow‐up studies are also now available, indicating that PDT has recurrence rates equivalent to other standard therapies in BD and superficial BCC, but with lower sustained efficacy than surgery in nodular BCC. In contrast, current evidence does not support the use of topical PDT for squamous cell carcinoma. PDT can reduce the number of new lesions developing in patients at high risk of skin cancer and may have a role as a preventive therapy. Case reports and small series attest to the potential of PDT in a wide range of inflammatory/infective dermatoses, although recent studies indicate insufficient evidence to support its use in psoriasis. There is an accumulating evidence base for the use of PDT in acne, while detailed study of an optimized protocol is still required. In addition to high‐quality treatment site cosmesis, several studies observe improvements in aspects of photoageing. Management of treatment‐related pain/discomfort is a challenge in a minority of patients, and the modality is otherwise well tolerated. Long‐term studies provide reassurance over the safety of repeated use of PDT.

British Association of Dermatologists’ guidelines for biologic interventions for psoriasis 2009

St John’s Institute of Dermatology, King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT U.K. *Department of Dermatology, Royal Gwent Hospital, Newport NP20 2UB, U.K. Department of Dermatology, Western Infirmary, Glasgow G11 6NT, U.K. The Dermatology Centre, Salford Royal Hospital, University of Manchester, Manchester Academic Health Science Centre, Manchester M6 8HD, U.K. §Psoriasis and Psoriatic Arthritis Alliance, PO Box 111, St Albans AL2 3JQ, U.K. –Department of Dermatology, Cardiff University, School of Medicine, Heath Park, Cardiff CF14 4XN, U.K. **Royal National Hospital for Rheumatic Diseases, Bath BA1 1RL, U.K. Department of Dermatology, Belfast City Hospital, Belfast BT9 7AB, U.K. Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE2 4HH, U.K. §§Department of Dermatology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB9 2ZB, U.K.

British Association of Dermatologists guidelines for use of biological interventions in psoriasis 2005

Psoriasis is a common, persistent, relapsing inflammatory skin disease that can be associated with significant morbidity. Quality of life studies in psoriasis reveal a negative impact on patients comparable with that seen in cancer, arthritis and heart disease.1–5 Patients with severe disease constitute approximately 20–30% of all patients with psoriasis, often require systemic treatment, and represent a major economic burden to the Health Service. All standard systemic therapies for severe disease are associated with the potential for major long-term toxicity, many are expensive, and a proportion of patients has treatmentresistant disease.6 Biological therapies or ‘biologics’ describe agents designed to block specific molecular steps important in the pathogenesis of psoriasis and have emerged over the last 3–5 years as potentially valuable alternative therapeutic options. Currently, biological therapies for psoriasis comprise two main groups: (i) agents targeting the cytokine tumour necrosis factor (TNF)-a (e.g. etanercept, infliximab, adalimumab) and (ii) agents targeting T cells or antigen-presenting cells (e.g. efalizumab, alefacept). Two of these, etanercept (Enbrel) and efalizumab (Raptiva) were licensed in 2004 in the U.K. for patients with moderate to severe psoriasis.

An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group Workshop Report.

Summary These guidelines for use of narrowband (TL‐01) ultraviolet B have been prepared for dermatologists by the British Photodermatology Group on behalf of the British Association of Dermatologists. They present evidence‐based guidance for treatment of patients with a variety of dermatoses and photodermatoses, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of background photobiology.

Cutaneous neoplasia following PUVA therapy for psoriasis

Summary To determine the risk of cutaneous neoplasia following photochemotherapy (PUVA), we reviewed patients with psoriasis treated at our unit between 1979 and 1991. Two hundred and forty‐five patients were assessed, with a median duration of follow‐up of 9·5 years. Fifty‐nine per cent wore male, and 41% female. The median number of exposures was 59. and the median total dose was 133 J/cm2 for the group as a whole. Non‐melanoma skin cancers (NMSC) occurred in six individuals (2·4%). Basal cell carcinoma occurred in fill six and one individual also developed four squamous cell carcinomas and Bowens disease of the penis. No cases of malignant melanoma were recorded. Patients who developed NMSC received a median number of 225 exposures and a median cumulative dose of 654J/cm2. Compared with a control study population in West Glamorgan. Wales, there was a 1·4 (95% confidence limits (CL) 0·5 and 3·1) times increased risk of NMSC. A statistically significant increased incidence of NMSC was found for patients who had received 100 or more exposures, and 250 or more J/cm2. with risks of 3·7 (95% CL 1·0 and 9·5). and 4.0 (95% CL 1·1 and 10). respectively. A PUVA dose of < 250J/cm2 or <100 exposures conferred a minimal increase in risk of NMSC in our study population.

Combination TL01 ultraviolet b phototherapy and topical calcipotriol for psoriasis: a prospective randomized placebo-controlled clinical trial

Summary Background Previous studies have demonstrated the ultraviolet (UV)‐sparing effect of combining topical calcipotriol with broadband UVB in the treatment of psoriasis.

British Association of Dermatologists and British Photodermatology Group guidelines for the safe and effective use of psoralen-ultraviolet A therapy 2015.

British Association of Dermatologists and British Photodermatology Group guidelines for the safe and effective use of psoralen–ultraviolet A therapy 2015 T.C. Ling, T.H. Clayton, J. Crawley, L.S. Exton, V. Goulden, S. Ibbotson, K. McKenna, M.F. Mohd Mustapa, L.E. Rhodes, R. Sarkany and R.S. Dawe Dermatology Centre and Dermatology Research Centre, Faculty of Medical and Human Sciences, Salford Royal NHS Foundation Trust, Salford, Manchester M6 8HD, U.K. Department of Dermatology, University College Hospital, 235 Euston Road, London NW1 2BU, U.K. British Association of Dermatologists, Willan House, 4 Fitzroy Square, London W1T 5HQ, U.K. Department of Dermatology, Leeds Teaching Hospitals NHS Trust, Leeds LS7 4SA, U.K. Department of Dermatology, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, U.K. Department of Dermatology, Belfast City Hospital, Belfast BT9 7AB, U.K.

PUVA and methotrexate therapy of psoriasis: how closely do dermatology departments follow treatment guidelines?

Following publication of treatment guidelines for patients with psoriasis, a six‐centre audit was undertaken to assess current therapeutic practice for two second‐line treatments, PUVA and methotrexate. The audit consisted of random sampling of casenotes by external auditors from a paired dermatology department, and assessment by questionnaire. One hundred and eight PUVA and 118 methotrexate casenotes were audited. The commonest indications for treatment were: (a) failure of topical therapy‐PUVA (mean 81% of casenotes), methotrexate (84%); (b) repeated hospital admissions‐PUVA (16%), methotrexate (25%).

Beta-thalassaemia minor and porphyria cutanea tarda.

Summary A case of porphyria cutanea tarda occurring in association with beta‐thalassaemia minor is reported in a 33‐year‐old Northern‐Irish woman. Aetiological factors in this case included oral and parenteral iron therapy for refractory anaemia which was subsequently diagnosed as beta‐thalassaemia minor, and the use of an oestrogen‐containing oral contraceptive pill.