Side Effect Of Phototherapy In Psoriasis

Two Photo-therapeutic regimens UVB and PUVA have been developed simultaneously for the treatment of psoriasis, and both have been shown to be highly efficient and have therefore remained in use.

The short-term side effects of UVB or PUVA are quite similar and consist of erythema (sunburn), dry skin with pruritus, swelling, and occasional phototoxic blisters; in addition, the frequency of recurrent herpes simplex increases. The major difference is in the time frame: Although UVB-induced erythema peaks before 24 hour, the maximal PUVA reaction is not reached before 72 hours. A generalized pruritus or tingling sensation may herald phototoxic side effects and should be taken as a warning sign. With large areas affected, systemic symptoms of phototoxicity such as fever and general malaise may occur. PUVA-induced skin pain unrelated to actual phototoxic burns occurs rarely but may necessitate temporary or definitive discontinuation of treatment.

In the initial phase of PUVA and UVB therapy, an asymptomatic and transient maculopapular eruption unrelated to phototoxicity has sometimes been seen. Psoralens can induce systemic side effects in the absence of light, mainly nausea and vomiting. In addition, they can rarely cause elevations of liver transaminases, central nervous system disturbance (headaches, dizziness), bronchoconstriction, drug fever, and exanthema. Because of higher permeability of the eye lens in children, PUVA should be avoided.

Long-term side effects of UV therapy include photoaging and carcinogenesis. A high cumulative dose of whole-body UVB or PUVA exposure results in pigmentary changes, xerosis, loss of elasticity, wrinkle formation, and actinic keratoses. In addition, PUVA may induce hypertrichosis and dark lentigines (“PUVA lentiginosis”).The major concern with prolonged and repeated phototherapeutic regimens is the induction or promotion of skin cancers. UVB is a known carcinogen, although its carcinogenic potential seems to be less than that of PUVA. In a 16-center study, no relationship between UVB phototherapy and nonmelanoma skin cancer was shown; however, the authors strongly cautioned that future studies may reveal an increased risk of nonmelanoma skin cancer with UVB phototherapy. The risk of squamous cell carcinoma, but not of basal cell carcinoma, is significantly increased in PUVA patients compared with matched controls, with the magnitude of the increase appearing to be dose-dependent.

There is uncertainty about the role of PUVA in these observations, however, because many of the reported patients had previous exposure to excessive sunlight and to other carcinogenic treatments such as arsenic, UVB, and methotrexate. Only a few anecdotal cases of malignant melanoma have been observed in psoriatic patients who received long-term PUVA treatment. The conclusion from different study was that the risk increases about 15 years after the first treatment, particularly after more than 250 treatments. This increased incidence is alarming, especially considering the long latency period for this tumor. This trend will likely become even more marked in the future.

It is unclear whether melanomas are associated with a certain cumulative UVA dose or with episodes of phototoxic burns. In addition, no increased risk of melanoma was found in other large-scale studies reported so far.Still, it is important to emphasize that a patient with long-term PUVA treatment must receive life-long monitoring. In any case, to possibly reduce melanoma risk, the cumulative UVA total dose should be kept to the minimum and maintenance therapy should be avoided.

Diet and Lifestyle Changes in the management of psoriasis

Psoriasis is a common chronic inflammatory disease involving a variety of factors affecting millions of patients worldwide. This disease is highly influenced by diet, lifestyle and environmental factors like stress and infection . It can occur at any age and can develop into chronic which is really fraustrating with major impacts on our quality of life. Based on the literature Diet and Lifestyle Changes doesn’t cure your psoriasis but may improve the response to psoriasis treatment.

Here are few things you need to change or avoid:

  • Limit or avoid alcohol intake.
  • Quit smoking.
  • Improve body composition.
  • Sleep 8 uninterrupted hours nightly.
  • Learn and practice daily an activity that elicits the relaxation response.
  • Exercise five to seven times weekly at a moderate level for 20 minutes.
  • Eat a nutrient-dense diet at the three main meals, and two to three small-meal snacks daily
  • a. Five or more servings of vegetables daily
    b. Two servings of fruit daily
    c. 8 to 12 ounces of protein-rich food daily (fish, chicken, turkey, lean meat, eggs)
    d. Whole grains, squash, sweet potatoes, beans; minimal refined carbohydrates
    e. Olive oil, coconut oil for cooking
    f. Small amounts of butter, cheese, and other dairy products
    g. Nuts and seeds if allergy is not an issue
    h. Consider a 3-month trial of a gluten-free diet
    i. Consider working with a nutritionist

    Good sleep hygiene
    1. Devote the time to sleep. Arrange consistent bedtimes and waking times to allow 7 to 8 hours of uninterrupted sleep.
    2. Begin unwinding 30 to 45 minutes before sleep should begin. Do not use this time to finish tasks, tidy up the house, or make to do lists.
    3. If you have worries, write them down and leave them for tomorrow.
    4. Try relaxation techniques as your prepare for bed.
    5. Do not eat 1 to 2 hours before bed. Do not drink a lot of fluids.
    6. Avoid caffeine (coffee, tea, chocolate) after 4 pm.
    7. Avoid alcohol 4 to 6 hours before bedtime.
    8. Avoid daytime naps.
    9. Exercise regularly and moderately. Do not engage in vigorous exercise after 6 pm.
    10. Do not keep the television in your bedroom.
    11. Use the bedroom only for sleep (and sex).
    12. Keep the bedroom quiet.
    13. Pull the shades so the room is dark. Light disturbs melatonin release.
    14. Ensure that the temperature of the bedroom is optimal for you.
    15. Consider putting a few drops of a high-quality lavender essential oil on a handkerchief under your pillow.
    16. Consider a bedtime ritual, such as a warm bath or a few pages of reading.

    Precautions:

    Diabetic retinopathy or neuropathy patients: avoid vigorous exercise
    Diabetic patients must monitor blood sugar before and after exercise. Delayed hypoglycemia can occur up to 6 to 15 hours after exercise.
    If you have the conditions listed above or have any concerns or questions, be sure to consult your physician before embarking on an exercise program.

    Source:Integrative Dermatology

    Indigo Ointment May Help Treat Patients With Psoriasis

    An ointment made from indigo naturalis, a dark blue plant-based powder used in traditional Chinese medicine, appears effective in treating plaque-type psoriasis, according to a report in the November issue of Archives of Dermatology, one of the JAMA/Archives journals.

    Psoriasis is a chronic skin disease for which no cure exists, only therapies that bring it into remission, according to background information in the article. “Traditional Chinese medicine is one of the most frequently chosen alternative therapies in China and Taiwan, and psoriasis has been treated for centuries with topical and oral herbal preparations,” the authors write. “Indigo naturalis is one of the Chinese herbal remedies that has been reported to exhibit potential antipsoriatic efficacy. However, long-term systemic use has been occasionally associated with irritation of the gastrointestinal tract and adverse hepatic [liver] effects.”

    Yin-Ku Lin, M.D., of Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan, and colleagues conducted a randomized trial of an ointment containing indigo naturalis in 42 patients with treatment-resistant psoriasis. Participants enrolled in the study between May 2004 and April 2005 and applied the indigo naturalis ointment to a psoriatic plaque on one side of their body (usually on the arm, elbow, leg or knee) and then a non-medicated ointment to a parallel plaque on the other side of their body. The researchers assessed and photographed patients’ skin plaques at the beginning of the study and again after two, four, six, eight, 10 and 12 weeks.

    After 12 weeks of treatment, the plaques treated with indigo naturalis ointment showed significant improvement in scaling, erythema (redness) and induration (hardening) when compared with the plaques treated with non-medicated ointment. “Weighting the sum of scaling, erythema and induration scores by the lesion area and comparing between the start and end of the study, the indigo naturalis ointment–treated lesions showed an 81 percent improvement, whereas the vehicle [non-medicated] ointment–treated lesions showed a 26 percent improvement,” the authors write.

    Of the 34 patients who completed the study, none experienced worsening psoriasis in the areas treated with indigo naturalis, while the treated plaques were completely or nearly completely cleared for 25 of them (74 percent). None experienced serious adverse effects. Four patients reported itching after applying the indigo naturalis ointment, but only for a couple of days at the start of treatment.

    “In conclusion, we present a randomized controlled trial showing the use of topical indigo naturalis ointment for the treatment of chronic plaque psoriasis to be both safe and effective,” the authors write. “Future research for a more potent extraction from this crude herb that can provide better absorption and convenience would help improve patient compliance with the treatment regimen. However, much more research will be necessary to clarify the pharmacology of indigo naturalis.”

    This study was supported by a grant from Chang Gung Memorial Hospital.

    Adapted from materials provided by JAMA and Archives Journals
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