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Before
your doctor prescribes PUVA therapy, the following steps
will generally occur:
evaluation by your doctor to
determine if PUVA therapy would be beneficial
assessment of any reasons you
should not have PUVA (contraindications)
full skin examination
eye examination, which will be
repeated yearly
recording of any other medications
you are taking to make sure no drugs that increase your
sensitivity to the sun are being
used (photosensitizing medications)
Should your doctor decide that
PUVA is right for you, s/he will review PUVA with you
and might ask you to sign a consent form (outlining
the risks and benefits of treatment) before administering
treatment. The PUVA treatment protocol can differ from
center to center. The two most common schedules are
to administer the therapy two or three times weekly.
Your dermatologist will decide how the psoralen is administered
(by mouth, bath or applying psoralen directly to a given
area).
If the disease is localized, such
as on the hands or feet, bath or topical PUVA is often
used. Instead of taking a pill, patients either soak
in a psoralen bath for 10 to 20 minutes or apply a psoralen
cream two hours prior to ultraviolet A exposure.
Both these methods have the advantage
of avoiding some of the side effects of oral psoralen
(e.g., nausea). These side effects are fewer because
the medication is not taken orally and therefore does
not enter the blood stream.
In general,
the following steps will occur in orally administered
PUVA therapy:
1. An oral dose of psoralen is
given two hours prior to exposure to UV light.
2. Genitalia must be covered.
3. The eyes must be completed shielded by protective
goggles.
4. UVA exposure occurs in a "light machine"
(dose is based on your skin type).
5. UV protective sunglasses must be worn after treatment,
especially outdoors. Exposure to sunlight
should be minimal.
6. UVA may be increased (increased time in the "light
machine" with subsequent sessions).
7. PUVA is given two or three times weekly until the
desired effect is obtained.
8. If your skin reddens, the treatment could be canceled,
or if redness is localized, the area can be
shielded with clothing or zinc oxide.
9. Once clear, you may be placed on a maintenance schedule
that requires you to return on a less
frequent but regular basis.
10. On non-treatment days, exposure to sunlight should
be minimized; outdoor use of sunglasses is
also encouraged.
PUVA therapy generally shows improvement
in the skin lesions within 6 to 10 treatments. Clearance
can often be obtained after 20 to 30 treatments—providing
that treatments are not missed and instructions are
followed.
Combination
Therapy with PUVA
PUVA may be combined with another
topical or oral treatment to increase the improvement
in psoriasis at the same or lower dose of UVA radiation.
Acitretin
(Retinoid) + PUVA (RePUVA)
Acitretin is an oral vitamin A
analogue, or retinoid that is given in combination with
PUVA. Your doctor will usually start you on acitretin
10 to 14 days before beginning PUVA therapy. This therapy
can be of particular use to those who have:
failed PUVA therapy alone
certain types of psoriasis (erythrodermic
or generalized pustular)
darker complexions
Pregnant women or women planning
a pregnancy should not receive acitretin.
Methotrexate
+ PUVA
Methotrexate can also be used
in combination with PUVA, a therapy that has been successful
in certain patients with severe psoriasis and psoriatic
arthritis. The patient can begin methotrexate two to
three weeks before PUVA therapy. Take methotrexate exactly
as directed by your doctor.
Balneotherapy (Climatotherapy)
The use of highly concentrated
salt water (greater than 20 percent) with ultraviolet
light is known as balneotherapy. Balneotherapy first
emerged as a treatment for various skin disorders in
Europe in the 1800s.
The Dead Sea in Israel is one
place balneotherapy is practiced. The Dead Sea has been
known to be of therapeutic benefit for psoriasis patients.
There are several scientific reasons for this: the Dead
Sea lies 400 m below sea level and UVB rays are largely
filtered out, leaving a higher concentration of UVA
rays, thereby allowing patients to expose their skin
for long periods without burning. Also, the Dead Sea
contains both salt (in concentrations 10 times higher
than ocean water) and a number of other minerals, such
as magnesium, calcium, potassium and bromine. These
minerals seem to enhance the beneficial effects of the
UVA.
Patients typically go to
the Dead Sea, bathe in the water and expose themselves
to the sunlight for several weeks. Many return every
year for relief of their psoriasis.
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