J. Krutmann H. Honigsmann C. A. Elmets P.R. Bergstresser (Eds.)

Dermatological Phototherapy and Photodiagnostic Methods

Springer-Verlag Berlin Heidelberg GmbH

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

Prof. Dr. Jean Krutmann Clinical and Experimental Photodermatology Heinrich -Heine-Universitiit MoorenstraBe 5 D-40225 Dusseldorf Germany

Prof. Dr. Helmut Honigsmann Abt. fur spezielle Dermatologie und Umweltdermatosen Universitiits-Hautklinik AKH Wiihringer Gurtel 18 - 20 A-1090 Wien Austria

Craig A. Elmets, M. D. Department of Dermatology University of Alabama at Birmingham SDB 67 Birmingham, AL 35294-0007 USA

Paul R. Bergstresser, M.D. Department of Dermatology UT Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, TX 75390-9069 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.

1. Skin-Disease-Phototherapy. 2. Skin-Diseases-Photochemotherapy. I. Krutmann, Jean, 1959-RL120.P48 D47 2001 616·5'0631-dC21

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© 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 10773859 22/3130 - 5 4 3 2 1 o -

ISBN 978-3-662-04513-8 ISBN 978-3-662-04511-4 (eBook)DOI 10.1007/978-3-662-04511-4

This book is dedicated to: Carl and Claudia Krutmann,

Laurie, Joshua, Michael, and David Elmets

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 (320-400 nm) Sylvania of the USA and narrow­band UVB (311- 312 nm) Philips of Holland which has now replaced broadband UVB, as the first-line therapy for psoriasis, and more recently UVA-1 (340-400 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.

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 1974. 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 1975. 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.

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-

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

Contents

I Basic mechanisms in Photo(chemo)therapy

UV Radiation, Irradiation, Dosimetry Ludwig Endres, Reinhard Breit . . . . . . . . . . . . . . . . . . . . . 3

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Photo(chemo)therapy for Atopic Dermatitis Jean Krutmann, Akimichi Morita . . . . . . . . . . . . . . . . . . . 93

Phototherapy and Photochemotherapy of the Idiopathic Photo dermatoses Adrian Tanew, James Ferguson . . . . . . . . . . . . . . . . . . . . . 109

Photo( chemo )therapy for Cutaneous T -Cell Lymphoma Herbert Honigsmann, Adrian Tanew, Paul R. Bergstresser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Phototherapeutic Options for Vitiligo Bernhard Ortel, Claudia Alge, Amit Pandy

Photo( chemo )therapy of Graft-V s-Host Disease

135

Beatrix Vole-Platzer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Phototherapy and Photochemotherapy: Less Common Indications for Its Use Thomas Schwarz, Anita Rutter, John Hawk

Phototherapy of HIV-Infected Patients: Evidence Questioning and Addressing Safety

178

Ponciano D. Cruz Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

XII Contents

Ill Special Phototherapeutic Modalities

Photodynamic Therapy in Dermatology Rolf-Markus Szeimies, Sigrid Karrer, Christoph Abels, Michael Landthaler, Craig. A. Elmets . . . . . . . . . . . . . . . . 209

Extracorporeal Photoimmunochemotherapy Robert Knobler, Peter Heald . . . . . . . . . . . . . . . . . . . . . . . . 248

Ultraviolet-A 1 Phototherapy: Indications and Mode of Action Jean Krutmann, Helger Stege, Akimichi Morita . . . . . . . 261

IV Photoprotection in daily practice

Acute and Chronic Photodamage from Solar Radiation, Phototherapy, and Photochemotherapy Henry W. Lim, Kristi J. Robson . . . . . . . . . . . . . . . . . . . . . 279

Photoprotection Peter Wolf, Antony Young . . . . . . . . . . . . . . . . . . . . . . . . . . 303

V Photodiagnostic procedures in daily practice

Photodiagnostic Modalities Norbert J. Neumann, Percy Lehmann . . . . . . . . . . . . . . . . 329

The Photopatch Test Erhard Holzle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338

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 . . . . . . . . . . . . . . . 371

Technical Equipment Helger Stege, Renz Mang........................... 381

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

List of Contributors

Christoph Abels, M.D. Klinik und Poliklinik fur Dermatologie, Universitat Reg ens burg, Franz-Josef-Strau6-Allee 11,

93052 Regensburg, Germany

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. Department of Dermatology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 - 9069, USA

Reinhard Breit, M.D. Theodor-Korner-Strasse 6, 82049 Pullach, Germany

Ponciano D. Cruz, Jr., M.D. Department of Dermatology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 - 9069, USA

Craig Elmets, M.D. Department of Dermatology, University of Alabama at Birmingham, SDB 67, Birmingham, AL 35294- 0007, USA

Ludwig Endres, Ph.D. Achheimstrasse 1a, 82319 Starnberg, Germany

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, 40225 Dusseldorf, Germany

John Hawk, M.D. Department of Environmental Dermatology, St. Thomas Hospital, London SE1 7EH, UK

Peter Heald, M.D. Department of Dermatology, Yale University School of Medicine, 333 Cedar Street, 501 LC1, New Haven, CT 06520, USA

XIV

Erhard Holzle, M.D. Department of Dermatology and Allergology, City Hospital Oldenburg, Dr.-Edenstrasse 10, 26133 Oldenburg, Germany

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,

93052 Regensburg, Germany

Robert Knobler, M.D. Department of Dermatology, 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, Moorenstrasse 5, 40225 Dusseldorf, Germany

Michael Landthaler, M.D. Universitats-Hautklinik, Franz-Josef-Strau:B-Allee n, 93053 Regensburg, Germany

List of Contributors

Kerstin Lang, M.D. Universitats-Hautklinik der Heinrich-Heine-Universitat, Moorenstrasse 5, 40225 Dusseldorf, Germany

Percy Lehmann, M.D. Universitats-Hautklinik der Heinrich-Heine-Universitat, Moorenstrasse 5, 40225 Dusseldorf, Germany

Henry W. Lim, M.D. Department of Dermatology, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202 - 2689, USA

Renz Mang, M.D. Clinical and Experimental Photodermatology, Heinrich-Heine-University, Moorenstrasse 5, 40225 Dusseldorf, Germany

Akimichi Morita, M.D., Ph.D. Department of Dermatology, Nagoya City University, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467- 8601, Japan

Warwick L. Morison, M.D. 10753 Falls Road, Suite S - 355, Lutherville, MD 21093, USA

Norbert J. Neumann Universitats-Hautklinik der Heinrich-Heine-Universitat, Moorenstrasse 5, 40225 Dusseldorf, Germany

List of Contributors

Wilfried H. G. Neuse, B.Sc. Universitats-Hautklinik, Heinrich-Heine-Universitat, Moorenstrasse 5, 40225 Dusseldorf, Germany

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. Department of Dermatology, Henry Ford Health System, Detroit, MI, USA

Anita Rutter, M.D. Wilhelms-Universitat Munster, Hautklinik, Von-Esmarchstrasse 56, 48149 Munster, Germany

Thomas Ruzicka, M.D. Heinrich-Heine-Universitat Dusseldorf, Moorenstrasse 5, 40225 Dusseldorf, Germany

Klaus Werner Schulte, M.D. Heinrich-Heine-Universitat Dusseldorf, Moorenstrasse 5, 40225 Dusseldorf, Germany

Thomas Schwarz, M.D. Hautklinik der Universitat Munster, Von-Esmarchstrasse 56, 48149 Munster, Germany

XV

Dr. med. Helger Stege, M.D. Clinical and Experimental Photodermatology, Moorenstrasse 5, 40225 Dusseldorf, Germany

Rolf-Markus Szeimies, M.D. Klinik und Poliklinik fur Dermatologie Regensburg, Franz-Josef-Strau6-Allee 11, 93053 Regensburg, Germany

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