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PUVA in the Age of Biologics

The author of this thorough review discusses the pluses and minuses of this treatment strategy for psoriasis.

The introduction of biologic agents that target various aspects of the immune system and the availability of narrowband UVB phototherapy have transformed how dermatologists care for psoriasis patients. PUVA remains an option and may still be the most appropriate form of therapy for some patients. The author of an excellent review carefully summarizes the pathogenesis of psoriasis and provides information about the mechanisms of action, indications, outcomes, adverse effects, and areas of uncertainty regarding the use of PUVA. Key points include:

• PUVA is very effective for moderate-to-severe psoriasis and can produce remissions of several months. The annual cost is estimated to be only 20% of that of biologic agents. However, an assessment of the relative efficacy of PUVA compared with other forms of therapy cannot be made: No controlled trials compare PUVA with biologics, and most studies evaluating the efficacy of PUVA were conducted before the use of the PASI score, which is widely employed to quantify effectiveness in moderate-to-severe psoriasis.
  
• Comparisons of narrowband UVB phototherapy with PUVA have shown that PUVA is more effective but is associated with more short- and long-term side effects.
  
• Patients exposed to more than 200 PUVA treatments are at increased risk for cutaneous malignancies. The risk is greatest for squamous cell carcinomas, but melanomas are also a risk. Metastases occur in 4% of PUVA-induced SCCs. Malignancies of the genitalia are a particular hazard. There is no evidence of increased risk for PUVA-related lymphoma or other noncutaneous malignancies.
  
• Patients with extensive disease, those with skin types III or IV (who are less likely to develop skin cancers), and those who have only a partial response to narrowband UVB are the best candidates for PUVA therapy. PUVA is also an option for individuals at risk for infection and those with a history of heart failure, hepatitis, liver disease, hematologic abnormalities, lymphoma, or demyelinating disorders.
  
• Scalp and nail involvement and psoriatic arthritis do not respond well to PUVA. Pregnancy; aphakia without a UVA-absorbing lens implant; a history of photosensitivity, including lupus; concomitant use of immunosuppressive agents; and a history of skin cancer or atypical nevi are also relative or absolute contraindications.
  

— Craig A. Elmets, MD

Published in Journal Watch Dermatology August 15, 2007

Citation(s):

Stern RS. Psoralen and ultraviolet A light therapy for psoriasis. N Engl J Med 2007 Aug 16; 357:682-90.

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