PUVA

PUVA stands for Psoralen and UVA treatment. Psoralens are found in plants and can be sensitized when taken either orally or when applied topically. Interestingly, they were used for this purpose in ancient Egypt but have only been commercially manufactured in the last four decades.
When used with UVA (long wave radiation) they allow for a lower dose of UVA.

PUVASOL is the use of psoralens with natural sunlight in areas such as India - research so far suggests it may be as good as conventional therapy.

• Eczema
• Psoriasis
• Vitiligo
• Mycosis fungoides
• Photodermatoses
• Localised scleroderma
• Skin changes associated with SLE

It remains a mystery as to why psoralens with UVA work in the above conditions but it has been postulated to relate to modulation of the skins immune system.¹

• Psoralen taken orally one hour before UVA treatment.
• If patient is unable to tolerate oral psoralens some hospitals provide a bathing system or topical psoralens e.g. gel based preparations.
• Topical therapy with psoralens is not associated with adverse effects such as nausea and vomiting seen with oral psoralens.
• During sessions patients need to wear protective goggles and UVA protective goggles must be worn for 24 hours following the treatment.
• Clothes only need to be removed from area to be treated, but groin protection is required.
• UVA treatment given 2-3x per week for about 12 weeks - in a light box.
• Once course finished may need maintenance therapy with one session per week.
• Avoid exposure to sunlight for 24 hours after the session.

1. Eye protection - wear goggles
2. Groin protection - wear protective shield/garment
3. Skin and eye protection for 24 hours following session of PUVA

Adverse effects from oral psoralen

• Nausea and vomiting - caused by psoralens and reduced if taken with food; common reason for stopping treatment
• Headache and dizziness

Adverse effects from combined psoralen and UVA

• Sunburn (phytotoxic erythema) and blistering - occurs 2-3 days after treatment and more often in fair skinned patients
• Dryness of skin with itching
• Tanning - lasts months (all patients)
• Keratitis - thus eyes need to be shielded during therapy

Adverse effects resulting from recurrent treatments

• Enhancement of aging changes of the skin - this includes freckling and wrinkling and occurs with extensive or prolonged treatments
• Increased skin neoplasia risk - e.g. melanoma and non-melanoma; again risk is higher with extensive and prolonged treatments

Psoriasis

• Used in older patients and those with severe psoriasis.
• Chronic-plaque type psoriasis is associated with up to 100% clearance.
• Efficacy is enhanced when combined with UVB or medications such as methotrexate (especially pustular and erythrodermic forms).
• PUVA therapy has been compared to narrow band UVB therapy in a randomised controlled trial which reported that the former is more effective.²

Eczema or dermatitis

• Moderate to severe eczema only - clearance in up to 75%

Mycosis fungoides

• Rare form of cutaneous T-cell lymphoma.
• PUVA can clear the disease but recurrence occurs in half of patients - with 30-50% remaining free of neoplasia at ten years.³
• Requires ongoing treatment over many years and thus may be associated with skin damage and neoplasia.³

Vitiligo

PUVA can lead to repigmentation in areas where there is complete loss of pigmentation - but results are variable.