Robert A. Sheehan-Dare

Improved response of plaque psoriasis after multiple treatments with topical 5-aminolaevulinic acid photodynamic therapy.

We investigated the clinical response of 10 patients with plaque psoriasis to multiple treatments with photodynamic therapy, using topical application of 5-aminolaevulinic acid followed by exposure to broad-band visible radiation. Treatment was performed up to 3 times per week, with a maximum of 12 treatments, using a light dose of 8 Jcm(-2) delivered at a dose-rate of 15 mW cm(-2). Eight patients showed a clinical response. Out of 19 treated sites, 4 cleared, 10 responded but did not clear and 5 showed no improvement. Of the 4 sites that cleared only 1 did so fully, after 7 treatments, 45 days after the start of therapy. Of the 10 sites that responded partially, the greatest reduction in scale, erythema and induration index occurred after a minimum of 3 and a maximum of 8 treatments. The intensity of 5-aminolaevulinic acid-induced protoporphyrin IX fluorescence, recorded prior to the first treatment, varied between sites on the same patient as well as between patients. There was also a variation in fluorescence intensity recorded from the same site immediately prior to subsequent treatments, although the pretreatment levels generally decreased as the study progressed and then increased as psoriasis relapsed. Biopsies confirmed that fluorescence was localized throughout the epidermis and stratum corneum, but the level was not consistent between sections taken within the same biopsy. We also observed fluorescence at sites distant from the ones that received 5-aminolaevulinic acid, which was not present prior to the start of the treatment programme, but found no evidence of elevated levels of plasma porphyrins. The level of discomfort associated with this therapy increased with increasing values of the calculated photodynamic dose, defined as the product of the initial photosensitizer concentration and the percentage reduction in fluorescence following irradiation. Therefore, although clinical efficacy improved with multiple treatments, unpredictable response and patient discomfort make ALA-PDT unsuitable for the treatment of psoriasis.

The variable response of plaque psoriasis after a single treatment with topical 5-aminolaevulinic acid photodynamic therapy

Summary We have investigated the clinical response of 22 patients with plaque psoriasis to photodynamic therapy using topical application of 5‐aminolaevulinic acid followed by a single exposure to broadband visible radiation. Light doses in the range 2–16J/cm2 delivered at dose rates of 10–40mW/ cm2 resulted in a variable clinical response. Seven (35%) patients showed clearing of psoriasis at some treated sites. The intensity of protoporphyrin IX fluorescence was recorded before, during and after treatment. Pre‐illumination fluorescence intensity varied considerably between sites on the same patient and between patients. Protoporphyrin IX fluorescence recovered and persisted after treatment for up to 14 days and became higher than preillumination levels at 25% of sites. The rate of protoporphyrin IX photo‐oxidation during treatment was proportional to both initial fluorescence intensity and incident light dose rate and was almost complete after I6J/cm2. We have defined the photodynamic dose as the product of time‐dependent protoporphyrin IX concentration and light dose and demonstrated that only in those patients who showed clearance of psoriasis was there a relationship between photodynamic dose and clinical response. Discomfort ranged from slinging through to burning, was significant in some patients and tended to be more severe with increasing photodynamic dose but was not predictable. Efficacy may improve by achieving consistent proto porphyrin IX levels or by using multiple treatments.

Hydroxyurea in the management of therapy resistant psoriasis

Eighty‐five patients with extensive chronic plaque psoriasis, unresponsive to conventional topical therapy, were treated with long‐term hydroxyurea in a dose of 0·5–1·5 g daily. Fifty‐two (61%) had a satisfactory remission during treatment without significant adverse effects. Treatment was discontinued in 33 patients (39%), due to an inadequate response or significant relapse during treatment and because of adverse reactions (19%). Four (4.7%) patients on hydroxyurea developed actinic psoriasis. Significant haematological abnormalities occurred in 30 patients (35%), but these became normal following a reduction in the dose of hydroxyurea or temporarily stopping the drug. In only six was it considered necessary to discontinue treatment because of bone marrow suppression. Our experience suggests that hydroxyurea is an effective long‐term treatment for psoriasis that is refractory to conventional topical therapy and that the incidence of serious adverse effects compares favourably with other cytotoxic drugs.

Digital calcification in systemic sclerosis : effective treatment with good tissue preservation using the carbon dioxide laser

Summary Tissue calcification of the fingers associated with limited systemic sclerosis is a common problem and is the source of considerable morbidity as it may be extremely tender and cause considerable functional disability. The current treatment of digital calcification is unsatisfactory. We evaluated the use of the carbon dioxide (CO2) laser in the management of this condition in six patients with the limited form of systemic sclerosis. A total of 21 areas of symptomatic digital calcification ofthe fingers were treated. Complete resolution of symptoms occurred in 12, moderate response with partial improvement was seen in five, little improvement was observed in two, and recurrence of calcinosis was found in two. The patients average healing time was 6 weeks (range 4–10). The median duration of follow‐up was 20 months (range 12–40). Postoperative infection was seen in two patients, and resolved completely in both wilh the use of topical and oral antibiotics. We found the CO2 laser a simple and effective treatment for most of the symptomatic lesions of digital calcification, and it may obviate the need for deforming surgery in many cases.

Investigation of the use of the pulsed dye laser in the treatment of Bowen's disease using 5-aminolaevulinic acid phototherapy.

Background  The use of 5‐aminolaevulinic acid photodynamic therapy (ALA‐PDT) for the treatment of Bowens disease is well established. However, treatment with a continuous light source has the disadvantage of prolonged treatment time during which patients often experience significant discomfort requiring the use of local anaesthetic.

Facial hirsutism treated with the normal-mode ruby laser : Results of a 12-month follow-up study

Fifty-one patients of skin type I to IV with facial hirsutism received treatment with the normal-mode ruby laser (950-micros pulse; 4-mm spot; mean fluence, 49 J/cm(2); maximum fluence, 66 J/cm(2)). For each patient, one site was treated once only, and a second site was treated 4 times at 4-week intervals. After 48 weeks, 46 patients were available for assessment. After a single treatment, hair counts were reduced to a mean of 45% at 4 weeks (pretreatment median of 63 hairs down to 26), increased to 80% (median, 51 hairs) at 12 weeks, were 65% (median, 41 hairs) at 24 weeks, and were 59% (median, 35 hairs) at 48 weeks. Four weeks after 3 treatments, the hair counts had reduced to a mean of 30% (pretreatment median of 68 hairs down to 15). Twelve weeks after 4 treatments, the hair counts had increased to 45% (median, 24 hairs) and were 39% after 36 weeks (median, 22.5 hairs). No anesthesia was needed. Treatment tolerance improved with consecutive visits, allowing higher fluences to be used. Hyperpigmentation developed in 9 patients, which had faded completely in 8 patients at the end of the study. One patient showed hypopigmentation. Depressions in the skin below the jaw line developed in 5 patients, which resolved completely within 4 to 32 weeks. We conclude that normal-mode ruby laser treatment is well tolerated and leads to significant improvement of facial hirsutism, which is maintained for at least 48 weeks. Repeated treatments result in greater clinical effects.

Eosinophilic angiocentric fibrosis—a rare mucosal variant of granuloma faciale which may present to the dermatologist

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Atrophie blanche–like scarring after pulsed dye laser treatment

Pulsed dye laser treatment is well established for the treatment of port-wine stains and other vascular skin lesions. Although hyperpigmentation is quite common, other side effects such as hypopigmentation and atrophic scarring occur infrequently, and hypertrophic scarring is rare.

Toxic pustuloderma due to PUVA treatment.

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Local molluscum contagiosum infection as a side‐effect of pulsed‐dye laser treatment

theless, pruritus remained severe in two patients, who considered withdrawal from antiviral therapy. Both patients were later able to complete the antiviral therapy by following the same dermatological treatment but with the addition of psychiatric treatment and support. We initiated a close follow-up of both patients, giving further emotional support, explaining the importance of continuing the antiviral therapy in a potentially serious disease such as CHC, and explaining that severe pruritus would finish at the end of therapy. In addition, and, most importantly, psychiatric treatment was initiated. After this multidisciplinary approach, the two patients were able to finish the 1-year antiviral therapy. Therefore, in our experience: (i) consideration of disruption of the standard combined 1-year antiviral therapy in patients with CHC due to eczema-like lesions was a rare event in our series (two of 210 patients), and (ii) in those patients presenting eczema with severe pruritus, the addition of psychiatric treatment may be of value. There is emerging evidence of a direct biological effect of hepatitis C virus on cerebral function, causing mild but significant neurocognitive impairment in CHC. In addition, it is well known that fatigue and psychiatric side-effects (depression, anxiety, anger ⁄ hostility) are frequently observed during this combined antiviral therapy. Secondary mood changes cause a deterioration in the quality of life of these patients and it can be speculated that they may also worsen their pruritus. To conclude, an interdisciplinary collaborative treatment must be initiated before considering premature withdrawal from antiviral therapy for CHC due to severe eczema-like lesions. Teams comprising dermatologists, hepatologists and psychiatrists may be of help in these cases.