PII: S0190-9622(84)80312-6Bilateral comparison of generalized lichen planus treated with psoralens and ultraviolet A Ernes to Gonza l ez , M . D . , Khosrow Momtaz-T, M.D . , and Stephen Freedman, M . D . Boston, MA
Ten patients with generalized lichen planus were treated with oral 8-methoxypsoralen photochemotherapy (PUVA) in a bilateral comparison study. Five patients (50%) cleared completely on both sides and required no maintenance treatment after a follow-up of up to 4 years. Three other patients (30%) improved at least 50% of their previous involvement. Most of the patients experienced symptomatic improvement of the treated side by the second week of the treatment. Two patients reacted adversely and exacerbated while receiving treatment to one side of the body. While preliminary, this bilateral comparison study demonstrates that PUVA is an effective therapy for generalized, symptomatic lichen planus and suggests that maintenance therapy might not be required once complete clearance is attained, Caution should be exercised, however, since some patients might develop an exacerbation of their disease with PUVA. (J AM ACAD DERNATOL 10:958-961, 1984.)
In 1978 Ortonne et aP reported the successful t reatment of l ichen planus with the use of oral 8-methoxypsoralen pho tochemotherapy (PUVA). Clinically, six o f seven patients cleared, while his- tologically five showed disappearance of epider- mal abnormalit ies, even though some still showed persistence o f a dermal, nonepidermotropic in- filtrate. Symptomat ic improvement was noticed early in the treatment. Since all these patients were treated in noncontrol led fashion, we decided to investigate a similar group of patients with gen- eralized lichen planus in a paired comparison study.
From the Department of Dermatology, Harvard Medical School and the Massachusetts General Hospital.
Presented at the Thomas B. Fitzpatrick 25th Anniversary Sym- posium, Lewis Tanenbaum, M.D., and Martin C. Mihm, Jr., M.D., editors.
Accepted for publication Sept. 16, 1983. Reprint requests to: Dr. Ernesto Gonzalez, Department of Dermatol-
ogy, Massachusetts General Hospital, Boston, MA 02114.
Tab le I. Characteristics of patients (10 patients)
Age Sex Race Percent involvement Duration of disease
Mean, 38 yr (23-66 yr) 4 male, 6 female 8 white, 2 black Mean, 32% (10%-60%) Mean, 7 mo (1-24 mo)
SUBJECTS
Ten patients with generalized, symptomatic, his- tologically proved lichen planus were the subjects of our study, They received treatment to one half of the body until clear before commencing exposure to the whole body. The unexposed side was covered with an opaque material that blocked ultraviolet radiation. All patients were treated three times a week following the PUVA protocol established for the treatment of psoria- sis ~''~ and other dermatoses.'l-7 Pictures were obtained before starting treatment and at different stages in the protocol. Clearing was attained when lesions were pigmented and nonpalpable, and this was confirmed in most of the cases by demonstrating no histologic evi- dence of lichen planus.
The characteristics of the patients studied are de-
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PUVA-treated generalized lichen planus 959
Table l I . Data for lichen planus patients receiving PUVA
Patient I Age l Sex l Skintype [ D~r2oti)~
1 50 M III 1 2 51 F II 2 3 35 F III 3 4 23 M II 24 5 32 F VI 3 6 24 F VI 5 7 59 F III 12 8 26 F III 6 9 42 M III 6
10 66 M III 5
Response No. of sessions Total UVA dose
0ottles/cm '~)
Cleared 32 Cleared 16 >50% improved I 1 (dropout) >50% improved* 26* >50% improvedt 16"I" Flared up Treatment failure Flared up Treatment failure Cleared 20 Cleared 38 Cleared 34
228 100 NA 214 NA
153 471.5 362
NA: Not *Cleared ]'Cleared
applicable. one side and 90% of the other side; relapsed but eventually cleared. one side; flare-up while treating other side = treatment failure.
picted in Table I. It is relevant to mention that two of the ten were black (skin type VI), since in the previous report by Ortonne et al I all of the patients were white. One of the patients had 60% involvement that included lesions of lichen planus of the palms, soles, and all twenty nails (twenty nail syndrome). The duration of the disease ranged from 1 month to 2 years, and many of these patients had received one or more courses of systemic corticosteroids with variable results but even- tual relapse. No treatments were given to the~e patients for at least 1 month prior to starting PUVA. All subjects were healthy except for one female patient who had lymphoma in remission, and she was off chemotherapy for 1 year prior to commencing PUVA.
R E S U L T S
Table II summarizes the response of the patients to PUVA. Of the ten patients entered, five cleared completely on both sides and these patients have been in complete remission for up to 4 years and have required no maintenance therapy (Figs. 1 and 2). Three other patients improved at least 50% of their previous involvement, including Patient 4, who cleared about 90% of his disease. This patient had a minor relapse after PUVA was discontinued, with new lesions developing on legs and arms, but he cleared completely on retreatment. The other relapse occurred in a black patient (Patient 5) who cleared on one side but developed an exacerbation of her disease as she was starting whole body treatment, with lesions involving prominently the
half of the body treated originally. This patient was considered a treatment failure and eventually cleared with a course of systemic steroids.
The other two treatment failures included a black patient (Patient 6) and a white patient (Pa- tient 7) who developed an exacerbation of their disease while receiving treatment to one side of the body. Both patients required hospitalization for symptomatic treatment and eventually im- proved with topical and intralesional cortico- steroids.
One patient (Patient 3) dropped out of the study after she had received eleven treatments to one side of the body. She was asymptomatic and had cleared at least 50% prior to discontinuation of her therapy. Except for the two patients who exacer- bated while receiving treatment to one side of the body, all other patients experienced symptomatic improvement on the treated side by the second week of treatment.
Table HI depicts the PUVA history for the pa- tients who cleared. The mean number of treat- ments required to clear one side was twenty- seven, while the mean dose to clear one side was 13.0 joules/cm 2, The mean cumulative dose to clear one side was 256 jouleslcm 2, and it required a mean of 6 weeks to clear one side. Table IV shows similar data for the treatment on the other side of the body on the patients in whom complete remission was obtained.
960 Gonzalez et al Journal of the
American Academy of Dermatology
Fig. 1. Anterior portion of trunk of Patient 8, demon- strating complete clearing of the left side after twenty PUVA treatments.
Fig. 2. Anterior portion of trunk of Patient 8 after the whole body was cleared with PUVA.
DISCUSSION
This preliminary, bilateral comparison study demonstrates that PUVA is an alternative therapy for generalized, symptomatic lichen planus and confirms previous observations made by Ortonne
Table III. PUVA history for clearing initial side !
Mean Range Parameter /
Treatments to clear one side 28 (16-38) Joules/cm ~ to clear one side 13 (10-17) Cumulative dose to one side 256 100-457.5) Duration of therapy to one side 6 (5-14)
(wk)
Table IV. PUVA history for clearing second side
Parameter [ Mean Treatments to clear other side 16 Joules/cln=' to clear other side 10 Cumulative dose to other side 115 Duration of therapy to other 5
side (wk)
(3-7)
et al. 1 Although the number of patients studied was smali, the findings so far suggest that mainte- nance therapy is not required once complete re- mission is attained. If this is confirmed in the future, it could be an attractive feature for this therapy since it will minimize the possible actinic effects of prolonged PUVA therapyY Caution should be exercised, however, since some patients might develop an exacerbation of their disease with PUVA.
Although the two black patients developed exacerbation of their disease while on P U V A , in only one (Patient 6) could we attribute the exacer- bation to an abnormal reaction to the treatment. The reaction on the other black patient (Patient 5) could have been due to inadequate treatment of the previously treated side while she was starting whole body therapy or to a phototoxic reaction since the patient received 26 joules/cm 2 to one half of her body by the end of the clearing phase. The fact that a white patient also had an exacerba- tion of her disease soon after starting PUVA miti- gates against the possibility that black patients with lichen planus will respond adversely to PUVA. Further studies are required to identify the population at risk from this adverse effect of PUVA.
Studies are in progress to determine the mech- anism of action of photochemotherapy on lichen planus.
Volume 10 Number 6 June, 1984
PUVA-treated general&ed lichen planus
REFERENCES
1. Ortonne JP, Thivolet J, Sanwald C: Oral photochemo- therapy in the treatment of lichen p/anus (L.P.). Br J Der- matol 99:77, 1978.
2. Parrish JA, Fitzpatrick TB, Tanenbaum L, Pathak MA: Photochemotherapy of psoriasis with oral methoxsalen and long-wave ultraviolet light. N Engl J Med 291:1207- 1212, 1974.
3. Melski JW, Tanenbaum L, Parrish JA, Fitzpatrick TB, Bleich HL, and 28 participating investigators: Oral methoxsalen photochemotherapy for the treatment of psoriasis: A cooperative clinical trial. J Invest Dermatol 68:328-335, 1977.
4. Gilchrest BA, Parrish JA, Tanenbaum L, Haynes HA, Fitzpatrick TB: Oral methoxsalen photochemotherapy of mycosis fungoides. Cancer 38:683-689, 1976.
5. Morison WL, Parrish JA, Fitzpatrick TB: Oral methoxsa- len photochemotherapy of recalcitrant dermatoses of the palms and soles. Br J Dermatol 99:297-302, 1978.
6. Morison WL, Parrish JA, Fitzpatrick TB: Oral psoralen photochemotherapy of atopic eczema. Br J Dermatol 98:25-30, 1978.
7. Parrish JA, Levine MJ, Morison WL, Gonzalez E, Fitzpatrick TB: Comparison of PUVA and beta-carotene in the treatment of polymorphous fight eruption. Br J Dermatol 100:187-191, 1979.
8. Stem RS, Thibodeau LA, Kleinerman RA, etal: Risk of cutaneous carcinoma in patients treated with oral methox- salen photochemotherapy for psoriasis. N Engl J Med 300:809-813, 1979.
Acquired, bilateral nevus of Ota-like macules Yoshiaki Hori, M.D., Makoto Kawashima, M.D., Kuniaki Oohara, M.D., and Atsushi Kukita, M.D. Nakakoma-Gun, Yamanashi-Ken, and Tokyo, Japan
Blue-brown macules of the face occurring on both sides of the forehead, temple, eyelids, malar area, alae of the nose, and root of the nose are often observed in middle-aged Japanese women. These lesions histologically are a form of dermal melanocytosis as shown by electron microscopic examination. They differ clinically from nevus of Ota. The differential diagnosis includes nevus of Ota, Riehl's melanosis (female facial melanosis), and melasma. The differences between them are discussed. (J AM ACAD DERMATOL 10:961-964, 1984.)
The nevus of Ota is usually unilaterally located in the areas innervated by the first and second branches of the trigeminal nerve. It is a macular lesion with a mixture of small brown patches and
From the Department of Dermatology, Yamanashi Medical College, Nakakoma-Gun, Yamanashi-Ken, and the Department of Der- matology, University of Tokyo Faculty of Medicine, Bunkyo-Ku, Tokyo.
Presented at the Thomas B. Fitzpatrick 25th Anniversary Sym- posium, Lewis Tanenbaum, M.D., and Martin C. Mihm, Jr., M.D., editors.
Accepted for publication Nov. 15, 1983. Reprint requests to: Dr. Yoshiaki Hori, Department of Dermatology,
Yamanashi Medical College, 1110, Shimokato, Tamaho-Mura, Nakakoma-Gun, Yamanashi-Ken, Japan 409-38.
blue macules, and it is usually congenital, but may appear later in life (in the second decade). The size and intensity of pigmentation may increase with advancing age. Pigmented macules are also often present in ocular, oral, or nasal mucosal membranes.1
Recently, we have observed acquired blue- brown maeules of the face occurring bilaterally on the forehead, temples, eyelids, cheeks, and/or nose. These macules are similar clinically to nevus of Ota, female facial melanosis (Riehl's melano- sis), or melasma. They usually appear in the fourth or fifth decade of life in Japanese women (only rarely in Japanese men) and are not observ- able in ocular and mucosal membranes.
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