PUVA Therapy In Bangalore

What is PUVA Therapy?

PUVA (Psoralen + UVA) therapy is a form of photochemotherapy that combines the use of psoralen compounds and controlled exposure to ultraviolet A (UVA) radiation. It has been an effective treatment for various severe skin diseases since its introduction in 1976.

Definition

Psoralens are natural compounds found in many plants that make the skin temporarily sensitive to UVA light. The ancient Egyptians were the first to use psoralen-containing plants for treating skin diseases thousands of years ago. Modern PUVA therapy utilizes synthetic psoralen derivatives like methoxsalen (8-methoxypsoralen), 5-methoxypsoralen, and trioxsalen.

Mechanism of Action

1. Psoralens enter the cells and intercalate between DNA base pairs.
2. Upon exposure to UVA radiation, psoralens absorb photons, become chemically activated, and covalently bind to DNA base pairs, forming crosslinks.
3. These DNA crosslinks have antiproliferative, antiangiogenic, apoptotic, and immunosuppressive effects, which contribute to the therapeutic benefits of PUVA therapy.
4. In the case of vitiligo, PUVA stimulates melanogenesis. The photoconjugation of psoralens in melanocyte DNA leads to mitosis, replication, and proliferation of melanocytes, increasing the number of melanosomes and their transfer to keratinocytes.

Conditions Treated with PUVA Therapy

PUVA therapy is primarily used to treat the following skin conditions:

Psoriasis

Psoriasis is a chronic, inflammatory skin condition characterized by thick, red, scaly patches called plaques. It is the most common condition treated with PUVA therapy. PUVA is particularly effective for severe, widespread psoriasis that does not respond well to topical treatments or UVB phototherapy alone.

Eczema

Eczema, also known as atopic dermatitis, is a chronic, inflammatory skin condition that causes dry, itchy, and inflamed skin. PUVA therapy can be an effective treatment option for severe, widespread eczema that does not respond to other treatments.

Vitiligo

Vitiligo is a condition that causes the loss of skin pigmentation, resulting in white patches on the skin. PUVA therapy can help repigment the affected

areas by stimulating melanocyte proliferation and increasing melanin production.

PUVA therapy is typically administered two to three times per week, with each session lasting 10-20 minutes. The number of treatments required can vary, but most patients need 20-30 sessions to see significant improvement in their skin condition.

The PUVA Therapy Procedure

Preparation

The PUVA therapy procedure begins with proper preparation. For oral systemic PUVA, patients must take methoxsalen (Oxsoralen Ultra) capsules by mouth 75 minutes before their scheduled appointment time. The dosage is tailored to each patient’s body weight, typically ranging from 0.4 to 0.6 mg/kg. Patients should follow the specific instructions on their prescription.

For hand and foot soak PUVA, patients mix methoxsalen with warm water in a prescribed ratio, creating an aquamarine solution. The affected areas are then soaked in this solution for 30 minutes before light exposure.

In the case of bath PUVA, patients dissolve a higher dose of methoxsalen in hot water and add it to a pre-filled bathtub with warm water. They soak from the shoulders down for 30 minutes, ensuring the face is not submerged.

Session Details

Once prepared, patients are guided to the UVA light box by nurses. Those receiving hand and foot soak PUVA use a specialized box accommodating only the treated areas, while systemic or bath PUVA patients step into a whole-body light box.

Nurses ensure all safety precautions are followed, including protective goggles and genital shielding. Patients are positioned to maximize light penetration and maintain this position throughout the treatment to prevent burns.

The nurse sets the light settings according to the patient’s needs, and the UVA light shines on the patient for a specific duration based on their individual dose. Patients must keep their eyes closed, wear goggles, and avoid touching the bulbs during the light exposure.

Post-Treatment Care

After each PUVA session, patients should take good care of their skin, as methoxsalen increases light sensitivity and susceptibility to sunburn. They should avoid sun exposure, even through window glass, for 24 hours after treatment.

Applying a broad-spectrum sunscreen with an SPF of 15 or higher to any exposed skin is crucial for at least 24 hours after PUVA therapy. Sunscreen should be reapplied every 1.5 hours when outdoors.

Patients should use moisturizers and lotions on the affected areas at least twice daily as part of their routine skincare regimen. They should also avoid scrubbing the skin, as trauma can worsen conditions like psoriasis through the Koebner phenomenon.

Limiting makeup, nail polish, perfumes, and colognes on treated areas is recommended to allow full light penetration and prevent photosensitivity reactions.

Side Effects and Risks of PUVA Therapy

Common Side Effects

PUVA therapy can cause various short-term side effects, including erythema (redness), pruritus (itching), burning sensation, skin dryness, and nausea. These side effects are generally mild and reversible after discontinuing treatment.

• Burning: An overdose of PUVA can result in a sunburn-like reaction called phototoxic erythema, which is more likely to occur in fair-skinned individuals. This reaction typically appears 48–72 hours after the first two or three treatments. Sensitive areas such as breasts and buttocks may need to be covered during treatment.
• Itching: Temporary mild pricking or itching of the skin is common after PUVA treatment. The skin may also become dry, necessitating frequent application of moisturizers. Antihistamine tablets can sometimes help alleviate itching.
• Nausea: Approximately one-quarter of patients treated with psoralens experience nausea. Taking methoxsalen capsules with food or reducing the dose can help minimize nausea. Antiemetic tablets can also be prescribed if needed.

Risk Management Strategies

Several measures can be taken to minimize the long-term risks associated with PUVA therapy:

1. Careful Patient Selection: Patients with chronic actinic damage, a history of skin cancer, previous arsenic intake, or ionizing radiation exposure may have a higher risk of developing skin cancers and should be carefully evaluated before initiating PUVA therapy.
2. Dose Reduction: Certain drug combinations or alternative psoralens with lower carcinogenic potential can be used to lower the cumulative UVA dose, reducing the risk of squamous cell carcinomas.
3. Shielding and Sun Protection: Shielding male genitalia during PUVA treatment is essential to reduce the risk of genital squamous cell carcinomas. Patients should also use sunscreen, protective clothing, and avoid sun exposure to minimize uncontrolled UV radiation exposure.
4. Regular Monitoring: Yearly dermatological examinations are highly advisable to detect skin cancer at an early stage and monitor for any precancerous or dyskeratotic skin conditions.
5. Informed Consent and Monitoring: PUVA therapy should be assigned based on the risk-benefit ratio for each individual patient and should be limited to those who can be monitored and controlled by informed, competent, and conscientious healthcare professionals.

FAQs

1. What is the cost range for PUVA therapy?

 This cost varies based on the provider and does not include any associated fees for visiting a phototherapist.

2. What is the duration of PUVA treatment?

PUVA treatment typically requires maintenance sessions for 2-3 months. After discontinuation, many patients remain symptom-free for a period of 6-12 months.

3. What medications are involved in PUVA therapy?

In PUVA therapy, methoxsalen capsules are commonly used, which patients take orally two hours before treatment. Alternatively, for bathwater PUVA, patients soak in a bath infused with a psoralen solution. Treatments are generally scheduled two to three times per week.

4. How is PUVA therapy administered?

PUVA therapy involves taking a tablet or applying a topical compound containing psoralens to make the skin more sensitive to light. Following this, the skin is exposed to ultraviolet A (UVA) light to complete the treatment.

Conclusion

PUVA therapy has proven to be an invaluable treatment option for various severe skin conditions, including psoriasis, vitiligo, and eczema. Its efficacy in reducing the severity of these conditions and improving the quality of life for patients is well-documented. However, it is crucial to weigh the potential benefits against the associated risks, particularly the long-term risks of premature skin aging and skin cancer.

By following proper safety measures, adhering to recommended dosages, and undergoing regular monitoring, patients can minimize the risks associated with PUVA therapy. Ultimately, the decision to undergo PUVA therapy should be made in consultation with a qualified healthcare professional who can evaluate the individual patient’s circumstances and provide guidance on the most suitable course of treatment.