J. Krutmann H. Honigsmann C. A. Elmets P.R. Bergstresser (Eds.) Dermatological Phototherapy and Photodiagnostic Methods

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1 J. Krutmann H. Honigsmann C. A. Elmets P.R. Bergstresser (Eds.) Dermatological Phototherapy and Photodiagnostic Methods

2 Springer-Verlag Berlin Heidelberg GmbH

3 J. Krutmann H. Honigsmann C. A. Elmets P.R. Bergstresser (Eds.) Dermatological Phototherapy and Photodiagnostic Methods With 104 Figures, so in Color, and 71 Tables i Springer

4 Prof. Dr. Jean Krutmann Clinical and Experimental Photodermatology Heinrich -Heine-Universitiit MoorenstraBe 5 D Dusseldorf Prof. Dr. Helmut Honigsmann Abt. fur spezielle Dermatologie und Umweltdermatosen Universitiits-Hautklinik AKH Wiihringer Gurtel A-1090 Wien Austria Craig A. Elmets, M. D. Department of Dermatology University of Alabama at Birmingham SDB 67 Birmingham, AL USA Paul R. Bergstresser, M.D. Department of Dermatology UT Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, TX USA Library of Congress Cataloging-in-Publication Data Dermatological phototherapy and photodiagnostic methods / J. Krutmann... [et al.] eds. p. cm. Includes bibliographical references and index. ISBN ISBN (ebook) DOI / Skin-Disease-Phototherapy. 2. Skin-Diseases-Photochemotherapy. I. Krutmann, Jean, RL120.P48 D '0631-dC21 This work is subject to copyright. AII rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permissions for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German copyright law. Springer-Verlag Berlin Heidelberg 2001 Originally published by Springer-Verlag Berlin Heidelberg New York in 2001 Softcover reprint ofthe hardcover 1st edition 2001 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product Liability: The publisher cannot guarantee the accuracy of any information about dosage and application thereof contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: design & production, Heidelberg Typesetting: Mitterweger & Partner, Plankstadt Printed on acid free paper SPIN / o -

5 This book is dedicated to: Carl and Claudia Krutmann, Laurie, Joshua, Michael, and David Elmets

6 Foreword One form of what was called heliotherapy 2000 years ago consisted of ingestion of an infusion (boiled extract) derived from a weed growing in the Nile Delta, Ammi majus L., followed by exposure to the Egyptian sun for the treatment of vitiligo, a disorder that was a serious disfigurement in this population with brown and black skin colored population. This crude treatment was the very earliest form of what is now called PUVA photochemotherapy, a treatment for psoriasis, vitiligo, and 34 other diseases and that uses the same chemical, psoralen, derived from the same plant source, Ammi majus L., and followed by exposure to specially designed computerized UVA irradiators. Phototherapy in the practice of dermatology was, in fact, not an efficacious and practical therapeutic option until as late as the mid-1970s, when lighting engineers, photophysicists, and dermatologists worked together to develop ultraviolet (UV) irradiators emitting high-intensity UVA. The UVA irradiators were designed to deliver uniform irradiation from fluorescent tubes lining a vertical cylinder in which the patient stands upright. The dose-delivery was computerized, and the doses were not designated in minutes but in joules (UVA) or in millijoules (UVB). The result was what has been termed photochemotherapy, which is defined as the use of chemicals that are "activated" by exposure of the molecules to radiant energy. The first example of photochemotherapy was the oral ingestion of a photoactive chemical, psoralen, followed by exposure to long-wave ultraviolet, UVA. The acronym PUVA was created and the modality represented the first use of light and drug together for a beneficial effect in humans. The introduction of PUVA was the driving force in the mid- 1970S that sparked a whole new series of discoveries during the next two decades, i.e., newly created high-intensity ultraviolet sources: UVA ( nm) Sylvania of the USA and narrowband UVB ( nm) Philips of Holland which has now replaced broadband UVB, as the first-line therapy for psoriasis, and more recently UVA-1 ( nm). These new effective therapies have been a boon particularly for patients with generalized psoriasis providing efficacious ambulatory treatments but avoiding the systemic problems of methotrexate and cyclosporin.

7 VIII Foreword The successful use of the new ultraviolet techniques for the treatment of disease was the "flywheel" for the development of a new sub-specialty called photomedicine, which encompasses all of the applications of the diagnosis and treatment of photoinduced disorders as well as the use of the new modalities such as photodynamic therapy for therapy of skin tumors and other diseases. There is now a Photo medicine Society and specialized journals of photodermatology. We should be aware that the modern methods of phototherapy and photochemotherapy are part of a whole new discipline requiring special equipment and special knowledge of photophysics and photochemistry, and there are at present a limited number of phototherapy centers in the world. In a manner of speaking, present-day phototherapy is comparable to the use of X-radiation therapy in dermatology with special hardware, specific indications, the selection of patients, and the need for careful and precise dosimetry. The practicing dermatologist needs to be educated to correctly use these sophisticated techniques, which have been evolved by large (over s,ooo patients using prospective randomized clinical trials in the United States and Europe), beginning in Alas, in the last two decades, although there was a new impetus for phototherapy, there has not been enough specialized training in phototherapy. Therefore, this updated practical manual is welcome. In this impressive volume, the indications and methodology of these various light sources are presented by an excellent international cadre of dermatologists experienced in the use of these various modalities. It is fitting that one of the editors is from Vienna because the Dermatology Department of the Vienna General Hospital was the second in the world to use PUVA in This detailed and up-to-date practical monograph is a "must" for any group doing phototherapy or contemplating a phototherapy unit. It is also a handy instruction manual for training personnel (technicians and residents) in phototherapy. Boston, USA, July 2000 Thomas B. Fitzpatrick, M.D. Ph.D.

8 Preface During the past 25 years, phototherapy has greatly influenced treatment concepts in dermatology. Consequently, photomedicine has developed from empiricism into one of the most exciting fields in biomedical research. Studies on the effects of visible and ultraviolet radiation on skin have led to a fruitful collaboration between basic scientists and clinicians. Thus, phototherapy may be regarded as a prime example of applied skin biology. UV radiation has been used for decades in the management of common skin diseases such as psoriasis and atopic dermatitis. More recently, the introduction of selective spectra in the UVB and UVA range such as narrowband UVB and UVA-1 phototherapy, as well as the inclusion of new indications, has much stimulated the interest in photodermatology. Visible light in combination with photosensitizers is currently in use for diagnosis and treatment of selected tumors. Extracorporeal photochemotherapy has proven to be effective beyond dermatology, in particular, in transplantation medicine. Most phototherapeutic regimens have been developed empirically and without knowledge about the biological mechanisms involved. Recent progress in the understanding of basic photobiological principles has made phototherapy more effective and, even more importantly, safer at the same time. The present handbook takes this dualism into account by presenting clinical information on the background of current knowledge of photobiological principles. Besides the detailed description of photo- and photochemotherapy for selected skin diseases, this volume contains standardized test protocols for photodermatoses and the diagnosis of skin tumors. There exists a variety of phototherapeutic modalities, and clinicians can now select the therapy of choice. A specific disease can thus be treated with the regimen that fits best the particular situation of a given patient. Therefore, the major focus of this volume is on the use of different treatment modalities for a specific disease. The clinically oriented chapters are supplemented by practical guidelines for phototherapy that have proven successful over many years. The leading experts have contributed to this project. Most of the authors are not only experienced clinical photodermatolo-

9 X Preface gists but also internationally renowned experts in basic photobiological research. We are very grateful to all authors for their excellent contributions. We hope that this monograph will serve as a state-ofthe-art reference for "Dermatological Phototherapy and Photodiagnostic Methods" in daily practice, clinical settings, and research. Kitzbiihel, Spring 2000 Jean Krutmann Herbert Honigsmann Craig A. Elmets Paul R. Bergstresser

10 Contents I Basic mechanisms in Photo(chemo)therapy UV Radiation, Irradiation, Dosimetry Ludwig Endres, Reinhard Breit Mechanisms of Photo( chemo )therapy Jean Krutmann, Akimichi Morita, Craig A. Elmets 54 II Photo(chemo)therapy in daily practice Photo(chemo)therapy for Psoriasis Herbert Honigsmann, Adrian Tanew, Thomas Ruzicka, Warwick L. Morrison Photo(chemo)therapy for Atopic Dermatitis Jean Krutmann, Akimichi Morita Phototherapy and Photochemotherapy of the Idiopathic Photo dermatoses Adrian Tanew, James Ferguson Photo( chemo )therapy for Cutaneous T -Cell Lymphoma Herbert Honigsmann, Adrian Tanew, Paul R. Bergstresser Phototherapeutic Options for Vitiligo Bernhard Ortel, Claudia Alge, Amit Pandy 135 Photo( chemo )therapy of Graft-V s-host Disease Beatrix Vole- Platzer Phototherapy and Photochemotherapy: Less Common Indications for Its Use Thomas Schwarz, Anita Rutter, John Hawk 178 Phototherapy of HIV-Infected Patients: Evidence Questioning and Addressing Safety Ponciano D. Cruz Jr

11 XII Contents Ill Special Phototherapeutic Modalities Photodynamic Therapy in Dermatology Rolf-Markus Szeimies, Sigrid Karrer, Christoph Abels, Michael Landthaler, Craig. A. Elmets Extracorporeal Photoimmunochemotherapy Robert Knobler, Peter Heald Ultraviolet-A 1 Phototherapy: Indications and Mode of Action Jean Krutmann, Helger Stege, Akimichi Morita IV Photoprotection in daily practice Acute and Chronic Photodamage from Solar Radiation, Phototherapy, and Photochemotherapy Henry W. Lim, Kristi J. Robson Photoprotection Peter Wolf, Antony Young V Photodiagnostic procedures in daily practice Photodiagnostic Modalities Norbert J. Neumann, Percy Lehmann The Photopatch Test Erhard Holzle Fluorescence Diagnosis with 6-Aminolevulinic Acid-Induced Porphyrins in Dermatology Clemens Fritsch, Kerstin Lang, Klaus-Werner Schulte, Wilfried H. G. Neuse, Thomas Ruzicka, Percy Lehmann 344 VI Appendix Practical Guidelines for Broadband UVB, Narrowband UVB, UVA-1 Phototherapy, and PUVA Photochemotherapy - A Proposal Herbert Honigsmann, Jean Krutmann Technical Equipment Helger Stege, Renz Mang Subject Index

12 List of Contributors Christoph Abels, M.D. Klinik und Poliklinik fur Dermatologie, Universitat Reg ens burg, Franz-Josef-Strau6-Allee 11, Regensburg, Claudia Alge, M.D. Abteilung fur spezielle Dermatologie und Umweltdermatosen, Universitats-Hautklinik AKH, Wahringer Gurtel 18-20, 1090 Vienna, Austria Paul R. Bergstresser, M.D. UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX , USA Reinhard Breit, M.D. Theodor-Korner-Strasse 6, Pullach, Ponciano D. Cruz, Jr., M.D. UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX , USA Craig Elmets, M.D. University of Alabama at Birmingham, SDB 67, Birmingham, AL , USA Ludwig Endres, Ph.D. Achheimstrasse 1a, Starnberg, James Ferguson, M.D. Photobiology Unit, Ninewells Hospital, Dundee, DD1 9S4, Scotland, UK Clemens Fritsch, M.D. Hautklinik and Institut fur Physiologische Chemie I, Heinrich-Heine-U niversitat Dusseldorf, Moorenstrasse s, Dusseldorf, John Hawk, M.D. Department of Environmental Dermatology, St. Thomas Hospital, London SE1 7EH, UK Peter Heald, M.D. Yale University School of Medicine, 333 Cedar Street, 501 LC1, New Haven, CT 06520, USA

13 XIV Erhard Holzle, M.D. Department of Dermatology and Allergology, City Hospital Oldenburg, Dr.-Edenstrasse 10, Oldenburg, Herbert Honigsmann, M.D. Abt. fur spezielle Dermatologie und Umweltdermatosen, Universitats-Hautklinik AKH, Wahringer Gurtel 18-20, 1090 Vienna, Austria Sigrid Karrer, M.D. Klinik und Poliklinik fur Dermatologie, Universitat Regensburg, Franz-Josef-Strau:B-Allee 11, Regensburg, Robert Knobler, M.D. Division of Special and Environmental Dermatology, University of Vienna Medical School, Vienna General Hospital - AKH, Wahringer Gurtel 18-20, 1090 Vienna, Austria Jean Krutmann, M.D. Clinical and Experimental Photodermatology, Heinrich-Heine-University, Dusseldorf, Michael Landthaler, M.D. Universitats-Hautklinik, Franz-Josef-Strau:B-Allee n, Regensburg, List of Contributors Kerstin Lang, M.D. Universitats-Hautklinik der Heinrich-Heine-Universitat, Dusseldorf, Percy Lehmann, M.D. Universitats-Hautklinik der Heinrich-Heine-Universitat, Dusseldorf, Henry W. Lim, M.D. Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI , USA Renz Mang, M.D. Clinical and Experimental Photodermatology, Heinrich-Heine-University, Dusseldorf, Akimichi Morita, M.D., Ph.D. Nagoya City University, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya , Japan Warwick L. Morison, M.D Falls Road, Suite S - 355, Lutherville, MD 21093, USA Norbert J. Neumann Universitats-Hautklinik der Heinrich-Heine-Universitat, Dusseldorf,

14 List of Contributors Wilfried H. G. Neuse, B.Sc. Universitats-Hautklinik, Heinrich-Heine-Universitat, Dusseldorf, Bernhard Ortel, M.D. Wellmann 2, 50 Blossom Street, Boston, MA 02114, USA Amit Pandy, M.D. Wellmann 2, 50 Blossom Street, Boston, MA 02114, USA Kristi J. Robson, M.D. Henry Ford Health System, Detroit, MI, USA Anita Rutter, M.D. Wilhelms-Universitat Munster, Hautklinik, Von-Esmarchstrasse 56, Munster, Thomas Ruzicka, M.D. Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Klaus Werner Schulte, M.D. Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Thomas Schwarz, M.D. Hautklinik der Universitat Munster, Von-Esmarchstrasse 56, Munster, Dr. med. Helger Stege, M.D. Clinical and Experimental Photodermatology, Dusseldorf, Rolf-Markus Szeimies, M.D. Klinik und Poliklinik fur Dermatologie Regensburg, Franz-Josef-Strau6-Allee 11, Regensburg, XV Adrian Tanew, M.D. Universitatsklinik fur Dermatologie, Abtlg. fur Spezielle Dermatologie und Umweltdermatosen, Allgemeines Krankenhaus der Stadt, Wahringer Gurtel 18-20, 1090 Vienna, Austria Beatrix Vole-Platzer, M.D. Division of Immunology, Allergy and Infectious Diseases, Department of Dermatology, University of Vienna Medical School, Wahringer Gurtel18-20, 1090 Vienna, Austria Peter Wolf, M.D. Universitatsklinik fur Dermatologie und Venerologie, Karl-Franzens-Universitat, Auerbruggerplatz 8, 8036 Graz, Austria Anthony R. Young, Ph.D. Photobiology Department, St. John's Institute of Dermatology, Guy's King/St. Thomas Hospital, London SE1 7EH, UK