Combination phototherapy of psoriasis with narrow-band UVB irradiation and topical tazarotene gel

Type:Uv phototherapy Time:2017-02-13 14:33:58

Stefanie Behrens, MD, Marcella Grundmann-Kollmann, MD, Ralf Schiener, MD, Ralf-Uwe Peter, MD, and Martina Kerscher, MD Ulm, Germany

Background: Narrow-band UVB (311 nm) phototherapy offering an emission spectrum closely conforming to the peak of the action spectrum for clearing psoriasis has significantly improved phototherapy for psoriasis. Because the majority of the commonly used topical therapies in treatment of psoriasis have limitations, a need for new topical agents remains. Tazarotene has been shown to be efficacious in plaque-type psoriasis. Combination of narrow-band UVB with topical agents has been shown to enhance efficacy of both treatment modalities.

Objective: We attempted to evaluate the efficacy of narrow-band UVB phototherapy in combination with topical tazarotene.

Methods: Ten patients with stable plaque psoriasis were treated with narrow-band UVB. In addition, topical tazarotene 0.05% was applied once daily to one side of the body. The follow-up period was 4 weeks. Efficacy was assessed separately for both body halves by means of a modified Psoriasis Area and Severity Index (PASI).

Results: Both treatment modalities notably reduced the PASI scores with values being significantly lower in skin areas treated with narrow-band UVB phototherapy in combination with topical tazarotene.

Conclusion: The addition of tazarotene to narrow-band UVB phototherapy promotes more effective, faster clearing of psoriasis compared with UVB (311 nm) monotherapy. (J Am Acad Dermatol 2000;42:493-5.)

Currently available topical treatments for pso-riasis include emollients, keratolytics, coal tar, corticosteroids, anthralin, and calcipotri-

ol. In the past decades several treatment regimens combining topical agents with phototherapy have been successfully used.1-3 However, because the majority of the commonly used topical therapies have major limitations, a need remains for new topi-cal treatments that have enhanced short- and long-term antipsoriatic effectiveness and an improved side effect profile and that are suitable for photo-combination therapies.

Tazarotene, the first member of a novel class of topical acetylenic retinoids, modulates 3 of the major pathogenic factors in psoriasis: it renders antiproliferative effects, normalizes altered keratinocyte differentiation, and decreases dermal and epidermal inflammation without many of the toxic-ity problems associated with systemic retinoid therapy.4-7 It is generally well tolerated and over-comes cosmetic problems (eg, the staining of clothes and skin caused by dithranol or the hyper-pigmentation caused by vitamin D3 analogs)8 associated with many other topical antipsoriatic therapies.6 Furthermore, tazarotene demonstrated significantly better maintenance of therapeutic effects after cessation of therapy in comparison with a potent topical corticosteroid in patients with plaque-type psoriasis.9

Over the past few years the development of irra-diation devices with new emission spectra has led to an expanded use for phototherapy in the treatment of a variety of dermatoses. One example is narrow-band UVB, peaking at 311 nm, which is highly effica-cious in plaque-type psoriasis and might even be less carcinogenic in comparison with broad-band UVB irradiation.3 Combination of narrow-band UVB with topical agents (eg, calcipotriol) enhances efficacy of both treatment modalities.

PATIENTS AND METHODS

To assess the efficacy of topical tazarotene in com-bination with narrow-band UVB therapy, 10 patients with stable plaque-type psoriasis were treated in a half-side manner. Psoriatic plaques on one side of the body were treated either with topical tazarotene 0.05% or an emollient once daily with random assignment of tazarotene to body half. The patients were instructed to apply a thin film of tazarotene gel to all psoriatic lesions on the designated side every evening. In addition, the whole body was treated with UVB 311 nm once daily 5 times a week by means of 28 TL 01 fluorescing bulbs (Phillips, Germany) with an intensity of 15.3 mW/cm2 (at a dis-tance of 20 cm) in a cubic ��UV 1000�� irradiation device (Waldmann, Villingen-Schwenningen, Germany). Depending on the individual skin type, the initial UVB 311 nm dose ranged from 0.15 to 0.31 J/cm2, with doses gradually increasing up to a maxi-mum UVB dose of 1.84 J/cm2.

RESULTS

Efficacy was assessed by means of a modified Psoriasis Area and Severity Index (PASI) separately for both body halves before therapy and once week-ly. A mean cumulative UVB 311 nm dose of 9.8 J/cm2 (SD �� 5.3) was applied with a mean number of 14 irradiations (range, 13 to 17). The median PASI score at baseline was 18.3 (95% CI, 15.01-20.50).

After 2 weeks both treatment modalities notably reduced PASI scores with values in all patients being

significantly lower (P<.05) in skin areas treated with narrow-band UVB in combination with topical tazarotene (median, 12.5) as compared with areas treated with narrow-band UVB alone (median, 14.0) (Fig 1). After 4 weeks, the median PASI reduction was 64% with the combination therapy and 48% with narrow-band UVB alone. For the body half assigned to UVB (311 nm) plus tazarotene, the median PASI score after 4 weeks had decreased to 6.5 (95% CI, 5.29-7.91) versus 9.5 (95% CI, 7.70-11.70) for the body half assigned to UVB monotherapy (P<.05).

Both treatment modalities were well tolerated with no significant tazarotene irritation and no sig-nificant phototoxicity in our combination therapy. Adverse effects of tazarotene gel were limited to mild local cutaneous irritation such as transient burning and erythema of the skin.

DISCUSSION

The presented data support the concept that in patients with stable plaque-type psoriasis, adminis-tration of topical tazarotene may enhance the thera-peutic efficacy of narrow-band UVB irradiation, with reduction of the mean number of treatment sessions and lower cumulative UVB doses. This is in accor-dance with our previous clinical study combining topical tazarotene with PUVA-bath therapy, in which the topical retinoid proved also to enhance the effi-cacy of balneophotochemotherapy.10 Moreover, one limitation of tazarotene monotherapy might be the induction of skin irritation in 23% of patients treated with tazarotene.6 Using the photocombination ther-apy this unwanted effect was markedly reduced, probably because of an enhanced skin barrier. Lehmann et al11 demonstrated that UVA- and UVB-irradiated skin is more resistant to irritants (eg, sodi-um lauryl sulfate) than unirradiated skin because of an enhanced skin barrier. This might also be the rea-son for the reduced irritation of tazarotene when applied in irradiated skin.

Although placebo-controlled multicenter studies in a large number of patients are not yet available, narrow-band UVB irradiation peaking at 311 nm combined with application of topical tazarotene gel seems to be an efficacious new treatment modality, which has the potential to develop into a first-line photocombination therapy in the treatment of psori-asis, especially in an outpatient setting.