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Keywords:
Atopic dermatitis, Elderly, Narrow-band ultraviolet B.
TO THE EDITOR
The prevalence of atopic dermatitis (AD) in elderly patients is
gradually increasing in developed countries [1]. In this paper, we report cases
of elderly Japanese patients with AD who were treated in our hospital with
narrow-band ultraviolet B (UVB, wavelength: 311 ± 2 nm) phototherapy and
discuss its utility as an adjunctive treatment for AD in older adults. We
describe two instructive cases in detail, then summarize clinical
characteristics of the AD and the efficacy of phototherapy for these cases and
four additional cases in Table 1.
Phototherapy regimens consisted of intensive treatment (three to five
irradiation sessions per week) and/or maintenance treatment (one irradiation
session every one to four weeks). As a practical consideration, rather than measuring
the minimal erythema dose (MED) in each case as is often done, we simply began
the first irradiation treatment for each patient with a dose of between 0.30
and 0.40 Joule (J)/cm2 (approximately half the value of the average
MED in the Japanese population [2]), on only in a small area of the skin
lesions. We then increased the dose by 0.05 J/cm2 at each subsequent
treatment until the optimal dose was achieved, as determined by effective
therapeutic response without adverse effects (e.g., marked irritation). The
assessment of therapeutic effects was defined as follows: clinical remission, disappearance of skin lesions in more than 95% of observed lesional areas for at
least three months with standard treatments and maintenance treatment of
narrow-band UVB; clinical improvement,
disappearance of skin lesions in more than 95% of observed lesional areas for at
least three months with standard treatments and maintenance treatment of
narrow-band UVB and either oral corticosteroids (betamethasone, ≤0.5 mg/day) or cyclosporine (≤50 mg/day); minor
improvement, mild to moderate improvement of lesional areas with standard treatments
and narrow-band UVB (intensive and/or maintenance treatments), with or without
oral corticosteroids/cyclosporine; and
ineffective. The standard treatments comprised regular application of
moisturizers and/or emollients in combination with topical corticosteroids and
tacrolimus, as well as oral antihistamines/cytokine-inhibitors [3]. Topical
tacrolimus was used for non-irradiated areas of skin lesions except for on the
days of irradiation treatments.
Case 1: A 64-year-old man
presented with refractory eczematous erythema on the face (atopic red face),
and lichenified eczema with localized prurigo-forming papules on the trunk and
extremities (Figure 1a). Serum laboratory tests revealed a prominent immunoglobulin (Ig)
E-allergic status. A biopsy of the
lichenified eczema revealed a chronic eczematous reaction with inflammatory
cell infiltrates, including numerous IgE-positive mast cells (MCs),
cluster of differentiation (CD) 11c+ dendritic cells (DCs), and CD1a+ DCs [4]. Previous treatments with standard therapies and oral
corticosteroids had achieved only moderate improvements. We therefore
administered narrow-band UVB phototherapy, which, after 12 irradiation
sessions, resulted in clinical remission of his refractory AD (Figure. 1b), allowing for withdrawal of
oral corticosteroids.
Case 2: A 76-year-old man
presented with chronic eczema on the face and lichenified eczema and/or
nummular-form eczema on the trunk and upper extremities. Laboratory data
indicated IgE-allergic
status. Skin biopsy showed
allergic-type infiltration of the lichenified eczema by IgE+ MCs, IgE+ CD11c+ DCs, and IgE+ CD1a+ DCs. He had a history of hepatitis C, in remission
since interferon therapy in his 50s. He had achieved moderate improvement of AD
through standard treatments and oral corticosteroids or cyclosporine, but
decreasing the doses of these resulted in AD relapse. We therefore administered
narrow-band UVB phototherapy concomitantly with ongoing oral
corticosteroids or cyclosporine.
Clinical improvement of the AD was observed at least once following
phototherapy (combined with standard treatments and occasional use of oral
cyclosporine). However, when we increased the dosage of narrow-band UVB
to 1.00 J/cm2 (in an effort to achieve clinical remission without
oral cyclosporine), the patient experienced marked deterioration at the areas
of the phototherapy, with emergence of severe eczema. We therefore discontinued
phototherapy.
Some older patients have difficulty managing AD using only standard
treatments, as a diminishing ability to perform normal activities of daily
living may inhibit adequate administration of topical medications. Therefore,
for moderate to severe cases of AD, powerful anti-inflammatory treatments like
oral corticosteroid or cyclosporine may be used in concert with the standard
treatments [1]; however, underlying conditions (e.g., hypertension, renal
dysfunction, and diabetes mellitus) in elderly patients with AD may preclude
the use of such treatments.
In the presented cases (Table
1), we used narrow-band UVB phototherapy as an adjunctive treatment. Given
its potent anti-inflammatory effects, we expected this treatment to provide
substantial relief from, or even cure AD. Using phototherapy, we achieved a
favorably therapeutic outcome for at least one in every six cases, and induced
clinical remission in two (cases 1 and 3) of the six cases (33%). In these two
cases, long-term clinical remission (³6 months) was also observed after
cessation of the phototherapy. One case (case 2) experienced a flare-up of
eczema following the 1.00 J/cm2 dose of narrow-band UVB, so we
discontinued his phototherapy. This exacerbation was likely due to exceeding
the patient’s non-identified MED-dose, resulting in an irradiation-induced
flare-up. Previous reports indicate that narrow-band UVB phototherapy is not
effective for treating acute severe exacerbations of AD [5], so following this
event, we only performed irradiation at doses over 0.70 J/cm2 in a
few select AD patients.
A recent study [6] demonstrated that the immunomodulatory effects of
narrow-band UVB phototherapy for AD are achieved via suppression of the immune
pathways of T-helper (Th)2, Th22, and Th1 cells and the associated decrease of
inflammatory infiltrating cells such as CD1a+ DCs, CD11c+ DCs, and Fc epsilon
receptor type 1 (FcεR1)+ cells in the lesional skin. In AD, complexes of IgE
and FcεR1 on the surface of IgE+ MCs, IgE+ CD1a+ DCs, and IgE+CD11c+ DCs may
capture large amounts of allergens resulting in induction of IgE-mediated
immediate, late-phase, and even ‘delayed-type’ hypersensitivity [1]. Thus, we
speculate that the efficacy of narrow-band UVB phototherapy for elderly
patients with AD in our hospital is due to suppressions of both
T-cell-activities and IgE-mediated allergic reactions in AD.
1. Tanei
R, Hasegawa Y (2016) Atopic dermatitis in older adults: a viewpoint from
geriatric dermatology. Geriatr Gerontol Int 16: 75-86.
2. Horio
T (2003) Phototherapy and photochemotherapy. In: Tamaki K, et al, eds. Comprehensive
handbook of clinical dermatology, Vol. 2. Tokyo: Nakayamashoten, p170-180 (in Japanese).
3. Saeki
H, Furue M, Furukawa F, Hide M, Ohtsuki M, Katayama I, et al. (2009) Guidelines
for management of atopic dermatitis. J Dermatol 36: 563-577
4. Tanei
R, Hasegawa Y, Sawabe M (2013) Abundant immunoglobulin E-positive cells in skin
lesions support an allergic etiology of atopic dermatitis in the elderly. J Eur
Acad Dermatol Venereol 27: 952–60.
5. Morita
A (2005) Newly developed phototherapy for atopic dermatitis. Allergol Int 54:
175-80.
6. Tintle
S, Shemer A, Suárez-Fariñas M, Fujita H, Gilleaudeau P, et al. (2011) Reversal
of atopic dermatitis with narrow-band UVB phototherapy and biomarkers for
therapeutic response. J Allergy Clin Immunol 128: 583-593.
7. Hanifin
JM, Thurston M, Omoto M Cherill R, Tofte SJ, et al. (2001) The eczema area and
severity index (EASI): assessment of reliability in atopic dermatitis. Exp
Dermatol 10: 11-18.
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