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 Table of Contents  
BRIEF REPORT
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 79-83

Comparative study of PUVA and NB-UVB in the management of chronic plaque psoriasis


Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India

Date of Submission29-Apr-2020
Date of Decision23-Feb-2021
Date of Acceptance01-Sep-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Angoori Gnaneshwar Rao
F12, B8, HIG-II APHB, Baghlingampally, Hyderabad, Telangana.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_26_20

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  Abstract 

Background: There are independent studies on PUVA and NB-UVB therapy for the treatment of psoriasis, but studies comparing both PUVA and NB-UVB are scarce. Aim: The aim of this study was to compare the efficacy and safety of PUVA and NB-UVB therapy in chronic plaque psoriasis. Materials and Methods: Fifty patients of chronic plaque psoriasis of more than 20% of body surface area and of more than 2 years duration with Psoriasis Area Severity Index (PASI) score of more than 10, aged above 12 years, were subjects in the study. PASI score was recorded. Patients were randomly allocated to one of the two groups, each consisting of 25 patients and administered therapy as per protocol: Group A: PUVA—psoralens + UVA or Group B: NB-UVB phototherapy. Therapeutic response of patients was followed up every week and PASI score was calculated at 0, 2, 4, 6, 8, 10, and 12 weeks. Observations: Commonest age group afflicted in both the groups was 31–40 years. There was significant improvement (P-value <0.0001) from baseline to 12th week in patients subjected to PUVA as well as NB-UVB therapy. In the PUVA group, minimum and maximum duration of treatment for PASI 75 was 5 and 11 weeks, respectively, whereas in the NB-UVB group it was 6 and 12 weeks, respectively. In the PUVA group, minimum and maximum number of exposures for PASI 75 was 10 and 22, respectively, and in the NB-UVB group it was 18 and 36, respectively. Conclusion: PUVA and NB-UVB are both effective therapies. However, NB-UVB is considered as good, effective, and safer treatment for plaque psoriasis with no or minimal long-term carcinogenic risk, and it can be safely used in children, pregnant women, and in patients with hepatic and renal insufficiency. However, more number of exposures and less energy (joules) are required in NB-UVB to achieve therapeutic target. Limitations: The number of cases in the study is less.

Keywords: NB-UVB, psoralen, psoriasis, PUVA


How to cite this article:
Gnaneshwar Rao A, Jagadevapuram K. Comparative study of PUVA and NB-UVB in the management of chronic plaque psoriasis. Indian J Drugs Dermatol 2021;7:79-83

How to cite this URL:
Gnaneshwar Rao A, Jagadevapuram K. Comparative study of PUVA and NB-UVB in the management of chronic plaque psoriasis. Indian J Drugs Dermatol [serial online] 2021 [cited 2022 Jan 25];7:79-83. Available from: https://www.ijdd.in/text.asp?2021/7/2/79/332419




  Introduction Top


Exposure to sunlight is the oldest treatment for psoriasis.[1] Both PUVA and NB-UVB are effective therapies in the treatment of psoriasis.[2] However, there is increasing concern about the long-term safety of PUVA because of increased risk of non-melanoma and melanoma skin cancers.[3],[4]


  Materials and Methods Top


The study was approved by the Medical College Ethics Committee. Patients with psoriasis attending outpatient department of dermatology of a tertiary care hospital from October 2016 to September 2018 (2 years) were subjects in the study. Informed consent was obtained from patients above 18 years of age and from parent/guardian in patients below 18 years of age. Fifty patients of biopsy-proven chronic plaque psoriasis involving more than 20% of body surface area, of more than 2 years duration with Psoriasis Area Severity Index (PASI) score of more than 10, and aged above 12 years of both sexes willing for study were included in the study. Subjects below 12 years of age, pregnant and lactating women or contemplating conception, photosensitive individuals, severe hepatic and renal disease, aphakia or cataract patients, and those unwilling for the study were excluded.

History and demographic data were recorded, and detailed cutaneous examination including nail and hair was carried out. Initial evaluation was done based on PASI score by estimating area of involvement, erythema, induration or thickening, and scaling in each region. Routine hematological, biochemical, and serological investigations, chest skiagram, and ophthalmic examination were carried out.

Fifty patients of chronic plaque psoriasis were randomly allocated to one of the two groups: Group A: PUVA—photochemotherapy or Group B: NB-UVB phototherapy. Twenty-five patients were included in group A who were asked to take tablet Methoxypsoralen 20 mg after food 2 h prior to the exposure of UVA light and was exposed to UVA with an initial dose of 2.0 J/cm2 twice weekly with 0.5 J/cm2 incremental dose. Twenty-five patients were included in group B who were administered NB-UVB therapy initially, started with a dose of 0.280 J/cm2 thrice weekly with 20% incremental dose. Both the groups were advised UV protection and were followed up every week, and PASI score was calculated at 0, 2, 4, 6, 8, 10, and 12 weeks. More than 75% reduction in PASI score was considered as complete remission and less than 25% reduction in PASI score as failure.

Statistical analysis

Data were analyzed by Microsoft Excel and GraphPad prism software. Data were summarized by mean ± SD for continuous data and percentages for categorical data. The comparison between the two groups was done by unpaired t-test/Mann–Whitney test for continuous data. The comparison between different time points within the group was done by repeated-measures one-way analysis of variance test and followed by post hoc multiple comparison test for continuous data. The association between the two groups was done by the χ2 test for categorical data. All P-values less than 0.05 were considered as statistically significant.


  Observations Top


In the PUVA group, the age of patients ranged from 24 to 56 years. The most common age group affected was 31–40 years 7 (28%), followed by 21–30 years 6 (24%), 41–50 years 6 (24%), and 51–60 years 6 (24%). In the NB-UVB group, the age of the patients ranged from 22 to 58 years. The most common age group affected was 31–40 years 10 (40%), followed by 51–60 years 8 (32%), 21–30 years 4 (16%) and 41–50 years 3 (12%).

Mean age in the PUVA group was 41.8 years and in the NB-UVB group was 41.7 years. By comparison, mean age in both the groups was statistically insignificant.

In both the groups, males were 18 (72%) and females were 7(28%), with a male to female ratio of 2.5:1.

In the PUVA group, the most common site of involvement was lower limbs in 24 (96%), followed by upper limbs in 23 (92%), trunk in 18 (72%), scalp in 8 (32%), and 1 (4%) on buttocks. In the NB-UVB group, the most common site of involvement was lower limbs in 23 (92%), followed by trunk in 21 (84%), upper limbs in 20 (80%), and scalp in only 9 (36%).

At baseline, minimum and maximum PASI scores in the PUVA group were 13.8 and 38.8, respectively. After 12 weeks of treatment, the PASI score was 0 and 6.4 with standard deviation of 6.6 at baseline and 2.2 at 12 weeks, respectively. There was significant improvement (P <0.0001) from baseline to 12th week in patients subjected to PUVA therapy [Figure 1] and [Figure 2].
Figure 1: (Original) (a) Psoriasis plaques at baseline and (b) resolution at the end of 12 weeks of PUVA therapy

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Figure 2: (Original) (a) Psoriasis plaques at baseline and (b) resolution at the end of 12 weeks of PUVA therapy

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At baseline, minimum and maximum PASI scores in the NB-UVB group were 14.4 and 37.2, respectively. After 12 weeks of treatment, the PASI score was found to be 0 and 7.7 with standard deviation of 6.2 at baseline and 2.0 at 12 weeks, respectively. There was significant improvement (P <0.0001) from baseline to 12th week in the patients subjected to NB-UVB therapy [Figure 3] and [Figure 4].
Figure 3: (Original) (a) Psoriasis plaques at baseline and (b) resolution at the end of 12 weeks of NB-UVB therapy

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Figure 4: (Original) (a) Psoriasis plaques at baseline and (B) resolution at the end of 12 weeks of NB-UVB therapy

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The mean reduction in PASI score at different time points was found to be more in the PUVA group when compared with NB-UVB group with P-value greater than 0.05. It implies that there was no statistical significant reduction in PASI score at 0, 2, 4, 6, 8, 10, and 12 weeks when both the groups are compared [Table 1].
Table 1: Comparison at different time points: PASI score in both groups

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In the PUVA group, percentage reduction of mean PASI score at 2nd week was 23.04% and at 12th week was 94.37%. In the NB-UVB group, percentage reduction of mean PASI score at 2nd week was 19.88% and at 12th week was 93.3%. Therefore, percentage reduction in mean PASI score at different time points is slightly more in PUVA than in NB-UVB when compared at baseline [Table 2]. Furthermore, PASI 100 was achieved by the PUVA group in 17 (68%) and by the NB-UVB group in 12 (48%). However, PASI 75 was achieved 100% by both the PUVA and NB-UVB groups at the end of 12 weeks.
Table 2: Comparison at different time points: percentage of PASI reduction in two treatment groups

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In the PUVA group, minimum and maximum duration of treatment for PASI 75 was 5 and 11 weeks, respectively. Mean duration of treatment was 8.6 weeks with a standard deviation of 1.47. In the NB-UVB group, minimum and maximum duration of treatment for PASI 75 was 6 and 12 weeks, respectively. Mean duration of treatment was 8.96 weeks with a standard deviation of 1.46. Mean duration of treatment for PASI 75 was more in the NB-UVB group than in the PUVA group, which was statistically insignificant with P-value greater than 0.05.

In the PUVA group, minimum and maximum number of exposures for PASI 75 was 10 and 22, respectively. The mean number of exposures was 17.2 with a standard deviation of 2.9. In the NB-UVB group, minimum and maximum number of exposures for PASI 75 was 18 and 36, respectively. The mean number of exposures was 26.9 with a standard deviation of 4.4. The mean number of exposures for PASI 75 was more in the NB-UVB group than in the PUVA group and it was statistically significant with P-value less than 0.0001.

In the PUVA group, minimum and maximum cumulative doses for PASI 75 were 42.5 and 159.5 J/cm2, respectively. The mean cumulative dose was 106.04 J/cm2 with a standard deviation of 29.1. In the NB-UVB group, minimum and maximum cumulative doses for PASI 75 were 21.68 and 82.1 J/cm2, respectively. The mean cumulative dose was 51.82 J/cm2 with a standard deviation of 15.8. The mean cumulative dose was more in the PUVA group than in the NB-UVB group and was statistically significant with P-value less than 0.0001.


  Discussion Top


Psoriasis is known to afflict all ages. In the present study, age of patients ranged from 22 to 58 years. The most common age group afflicted was 31–40 years (34%), correlating with the study by Okhandiar and Banerjee,[5] in which highest incidence was seen in the 20–39 year age group. In our study, males (72%) outnumbered females (28%), with male to female ratio of 2.5:1, which is in concurrence with the study by Bedi[6] (2.5:1), Okhandiar et al. (2.46:1), and Dogra and Yadav[7] (2.03:1). Most of our patients (88%) presented with itching, which is similar to the studies by Okhandiar et al. (95%) and Bedi (81%).

In the present study, psoriasis involved mostly extensors of lower limbs (94%) and upper limbs (86%), followed by trunk (78%) and scalp (34%), which is in concurrence with the study by Okhandiar et al., in which extensors (93%) were the most common site of involvement followed by the scalp.

In the PUVA group, mean PASI at baseline was 38.8 and at 12th week it was 6.4. Therefore, percentage reduction of mean PASI score was 94.37%. The mean duration of treatment was 8.6 weeks. The mean number of exposures was 17.2 and mean cumulative dose was 106.04 J/cm.2 In the NB-UVB group, mean PASI at baseline was 37.2 and at 12th week 7.7. Therefore, percentage reduction of mean PASI score was 93.3%. The mean duration of treatment was 8.96 weeks. The mean number of exposures was 26.9 and the mean cumulative dose was 51.82 J/cm2. So, when both the treatment groups are compared, it can be inferred that percentage reduction of mean PASI score was more in the PUVA group but was statistically insignificant. This indicates equal efficacy of both the treatment groups with good clearance at the end of 12th week. Notably, there was no differential improvement in different sites with both PUVA and NB-UVB therapies. The mean duration of treatment for PASI 75 was more or less equal in both the groups. These observations in our study correlate with an open, randomized, controlled study of 54 patients in which 29 received NB-UVB (three times a week) and 25 received PUVA (twice weekly). Those in the PUVA group required significantly fewer treatments for clearance. There was no significant difference in the number of days to clear, and NB-UVB phototherapy was as effective as 8-MOP-PUVA.[8] Our study is also in concert with the study by Tanew et al.,[9] who corroborated that both treatments were equally effective but opined that oral 8-MOP-PUVA was superior for patients with severe plaque psoriasis, which could not be demonstrated in our study.

Interestingly, in a study by Gordon et al.,[10] PUVA was found to be more effective for psoriasis than NB-UVB phototherapy when given twice weekly, but in our study NB-UVB was administered thrice weekly. However, in the present study, the mean number of exposures was more in the NB-UVB group whereas mean cumulative dose was more in the PUVA group which was statistically significant (P < 0.0001). Additionally, our study concurs with the study by Dayal et al.,[11] in which number of exposures ranged from 6 to 26 for PUVA and 10 to 32 for NB-UVB. Similar results were also observed in the study by Shenoi and Prabhu,[12] in which the number of exposures ranged from 15 to 25 with cumulative dose of 103 J/cm2.

In the present study, adverse effects were seen more in the PUVA group (60%), whereas only 20% was in the NB-UVB group and was statistically significant. Pruritus and mild erythema were seen in both the groups but nausea and moderate erythema were noticed only in the PUVA group. However, none of the adverse effects was significant enough to warrant withdrawal from the study. Our study is in concert with the study of Markham et al. and Tanew et al., which showed that both PUVA and NB-UVB therapies are erythemogenic, but mild erythema was seen in NB-UVB whereas mild and moderate erythema in the PUVA group. Various studies observed that the risk of long-term side effects of carcinogenesis was more with PUVA treatment.[3]


  Conclusions Top


Both PUVA and NB-UVB are effective therapies. However, NB-UVB is considered as good, effective, and safer treatment for chronic plaque psoriasis with no or minimal long-term carcinogenic risk, and it can be safely used in children, pregnant women and in patients with hepatic and renal insufficiency. However, more number of exposures and energy are required in NB-UVB to achieve the therapeutic target. PUVA offers only few advantages of faster clearance with lesser number of exposures making less number of hospital visits.

Limitations

The number of cases in the study is less.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Christophers E. Psoriasis—Epidemiology and clinical spectrum. Clin Exp Dermatol 2001;26:314-20.  Back to cited text no. 1
    
2.
Archier E, Devaux S, Castela E, Gallini A, Aubin F, Le Maître M, et al. Efficacy of psoralen UV-A therapy vs. narrowband UV-B therapy in chronic plaque psoriasis: A systematic literature review. J Eur Acad Dermatol Venereol 2012;26(Suppl. 3):11-21.  Back to cited text no. 2
    
3.
Stern RS, Laird N. The carcinogenic risk of treatments for severe psoriasis. Photochemotherapy follow-up study. Cancer 1994;73:2759-64.  Back to cited text no. 3
    
4.
Stern RS; PUVA Follow-up Study. The risk of melanoma in association with long-term exposure to PUVA. J Am Acad Dermatol 2001;44:755-61.  Back to cited text no. 4
    
5.
Okhandiar RP, Banerjee BN. Psoriasis in the tropics: An epidemiological survey. J Indian Med Assoc 1963;41:550-6.  Back to cited text no. 5
    
6.
Bedi TR. Psoriasis in North India. Geographical variations. Dermatologica 1977;155:310-4.  Back to cited text no. 6
    
7.
Dogra S, Yadav S. Psoriasis in India: Prevalence and pattern. Indian J Dermatol Venereol Leprol 2010;76:595-601.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Markham T, Rogers S, Collins P. Narrowband UV-B (TL-01) phototherapy vs. oral 8-methoxypsoralen psoralen-UV-A for the treatment of chronic plaque psoriasis. Arch Dermatol 2003;139:325-8.  Back to cited text no. 8
    
9.
Tanew A, Radakovic-Fijan S, Schemper M, Hönigsmann H. Narrowband UV-B phototherapy vs. photochemotherapy in the treatment of chronic plaque-type psoriasis: A paired comparison study. Arch Dermatol 1999;135:519-24.  Back to cited text no. 9
    
10.
Gordon PM, Diffey BL, Matthews JN, Farr PM. A randomized comparison of narrow-band TL-01 phototherapy and PUVA photochemotherapy for psoriasis. J Am Acad Dermatol 1999;41:728-32.  Back to cited text no. 10
    
11.
Dayal S, Jain VK, Mayanka. Comparative evaluation of NBUVB phototherapy and PUVA photochemotherapy in chronic plaque psoriasis. Indian J Dermatol Venereol Leprol 2010;76:533-7.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Shenoi SD, Prabhu S; Indian Association of Dermatologists, Venereologists and Leprologists. Photochemotherapy (PUVA) in psoriasis and vitiligo. Indian J Dermatol Venereol Leprol 2014;80:497-504.  Back to cited text no. 12
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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