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1、银屑病光疗和光化学疗法的研究进展（Advances in phototherapy and photochemical therapy for psoriasis）Since 1925, Goeckerman will be used for the treatment of psoriasis with topical tar preparations and ultraviolet radiation, and ultraviolet light therapy has become more and more widely used in the treatment of psorias
2、is. In 1953, Ingram achieved good results in the treatment of psoriasis with UVB and UVB, which has been used for half a century. With the deep understanding of ultraviolet light, in 1970s, it was found that oral administration of psoralen combined with long wave ultraviolet (UVA) radiation photoche
3、mical therapy (PUVA) is more effective in the treatment of psoriasis. Since the late 1980s, there has been a narrow wave UVB 311-313nm wavelength, and recently 308nm excimer lasers, which have made unprecedented progress in the treatment of psoriasis with ultraviolet light. The recent progress of ul
4、traviolet light therapy and photochemical therapy for psoriasis is summarized as follows.The mechanism of ultraviolet treatment of psoriasisUVB and UVA play a major role in the treatment of multiple skin diseases by modulating the skin immune system, 1. UVB radiation can cause the nucleus DNA to for
5、m light polymers, inhibit the synthesis of DNA, and then inhibit the proliferation of epidermal cells DNA in psoriatic patients. UVB can increase the tumor suppressor gene product p53, p53, and control the cell cycle, thus UVB can play an important role in prolonging the circulating cycle of psoriat
6、ic patients. UVB or UVA after irradiation can induce keratinocytes to produce cytokines and inhibit the anti-inflammatory or immune neural polypeptide, prostaglandin and other media play a role in immune regulation, change the Langer Hans cells antigen presenting function. Walters 2 research shows t
7、hat narrow-band UVB irradiation. The skin lesions of patients with psoriasis of interleukin -12mRNA and interferon gamma mRNA decreased obviously, at the beginning of narrowband UVB treatment within 1-2 weeks of the activity of T cells to produce interferon gamma by 40%-65%, opposite during the narr
8、ow wave UVB on interleukin -4mRNA can be increased to 82%, narrow the wave of UVB after 1 weeks of treatment, interleukin -4 production can be increased by 228%. The narrow band UVB can inhibit T cell subtypes especially selective activation of Th1 cells, selective reduction of proinflammatory cytok
9、ine products. In addition, UVB and UVA irradiation can modulate the expression and function of adhesion molecules, cytokines, growth factors and other receptors, and inhibit the infiltration of inflammatory cells by inhibiting the expression of intercellular adhesion molecule -1.The most important m
10、echanism of UV treatment for psoriasis is to induce the infiltration of T cells in psoriatic skin lesions. Narrow wave UVB has more penetrating power than 290-320nm, wide wave UVB, and even causes a large number of T cell apoptosis in dermis, which is one of the reasons why narrow wave UVB is better
11、 than wide wave UVB. Ozawa 3 research shows that the two UVB can reduce the epidermis of psoriatic lesions in different parts of the T cells, but the narrow wave UVB wide UVB wave to reduce the number of T cells is more significant, narrow wave UVB reduce dermal CD3+T cells is less than that of wide
12、 UVB wave. Flow cytometry study showed that the decrease of CD3+, CD4+ and CD8+T cells in the epidermis occurred in the initial narrow wave UVB treatment for 2 weeks, and TUNEL was used to prove that the apoptotic cells were T cells.PUVA can cause skin phototoxic reaction, thymine Psoralen in the pr
13、esence of UVA and DNA in epidermal cells on the strand synthesis reaction, the structure of new generation, can make the DNA replication and cell division by inhibiting epidermal hyperplasia, slow down. PUVA can also increase the activity of melanocytes, increase the amount of melanin, and promote t
14、he formation of melanin. Apoptosis caused by active T cells is also an important mechanism of PUVA in the treatment of psoriasis 4.Two narrow wave UVBOn 1981 Parrish showed that the increase of the shorter wavelength caused by ultraviolet erythema and carcinogenicity of 295nm following UVB almost no
15、 anti psoriasis activity, only cause skin burns, while 300-313nmUVB can make psoriasis was the largest degree, more than 313nm less effective. The narrow wave UVB generated by this theory is used in clinical practice and has achieved good results. The narrow wave UVB tube used now is the TL-01 type
16、produced by PHILPS, the major wave crest located at 311-313nm,For the treatment of psoriasis and other skin diseases, proved to be effective. Wide wave UVB each course of treatment of psoriasis treatment need 25 or more times, 15-50 times the maximum amount can reach the initial amount, and the effe
17、ct is better than that of narrow band UVB on psoriasis wide wave UVB, times of treatment and carcinogenicity was significantly reduced, in Europe has almost replaced the narrow band UVB and wide UVB wave, and even many scholars believe that the narrow the effect of UVB wave almost equivalent to PUVA
18、, but the side effect was significantly lower than that of PUVA5. Narrow wave UVB treatment of psoriasis according to minimal erythema dose (MED) or sun reactive skin types to determine the radiation dose, the initial dose of 70-100%MED, according to the degree of skin reaction after phototherapy gr
19、adually increasing doses usually increase 10-20%, for obvious reaction after phototherapy, to reduce the radiation dose or after the reaction subsided shine again. 2-5 times a week, the faster the irradiation, the better the effect, but the more itching, erythema, itching and other side effects caus
20、ed by radiation. Hofer 6 takes 70%MED as the initial volume and the initial amount of 3-5 times a week in treatment of psoriasis vulgaris with 35%MED, at a dose increase under the same conditions are equally effective, but the former was eliminated quickly, but accumulated less of the latter and the
21、 potential carcinogenicity of smaller, they think the irradiation initial amount may not need to close to MED. Many scholars have conducted the research on the frequency of narrow band UVB in the treatment of psoriasis, such as Dave 7 of treatment 5 times a week, 35 days can make the skin lesions su
22、bsided 3 times a week, such as the 40 Tianda the same treatment effect, but the latter is caused by itching, erythema, blisters and side effects decreased significantly. Cameron and other 8 researchers believe that 3 treatments per week are better than 2 times a week and can quickly remove lesions.
23、Many studies have concluded that 3 narrow-band UVB irradiation every week is more effective and less harmful in the treatment of psoriasis.Markham 9 recently in a randomized controlled trial comparing open narrow wave UVB and oral 8- Methoxypsoralen (8-MOP) PUVA in the treatment of chronic plaque ps
24、oriasis, 54 patients were randomly divided into narrow wave UVB treatment group and PUVA treatment group were given 3 times a week or a week MED narrow wave UVB 2 MPD (MPD) PUVA treatment, the results showed that PUVA the number of treatments needed narrow wave UVB less, but the total treatment dura
25、tion of remission and no significant difference between the two groups, the two groups had similar proportions of patients with detectable erythema, pruritus and polymorphous light eruption, only PUVA group had nausea. The authors believe that 3 narrow wave UVB per week and 2 weekly PUVA are equally
26、 effective for chronic plaque psoriasis, and the narrow wave UVB adverse reactions are significantly lower than PUVA. But Gordon 10 is also considered 2 times a week for the treatment of plaque psoriasis lesions when the knees subsided over parts or treatment to stop after 16 times, PUVA 83% elimina
27、tes the skin lesions of patients with narrow UVB wave therapy, only 63% (P=0.018), PUVA less treatment times to narrow wave UVB, after 6 months PUVA treatment with 35% patients still alleviated, and narrow wave UVB therapy only 12% remission, the researchers believe that it is 2 times a week when th
28、e irradiation effect of PUVA is better than narrow UVB wave. Methods Dawe 11 control compared with about three narrow wave UVB and 8-methylpsoralen (TMP) effect of PUVA water bath treatment of chronic plaque type psoriasis, that narrow band UVB is more effective than TMP in water bath for PUVA, but
29、no significant difference between the remission stage.Narrow wave UVB can be used in combination with many drugs, which is superior to narrow wave UVB alone, and reduces adverse reactions. Vitamin D3 derivatives, they increase the efficacy of narrow wave UVB, reducing the cumulative UVB of narrow wa
30、ve 12. Hofmamn 13 research shows that narrow wave UVB and Calcipotriol Ointment (3 g/g, 2 times a day) or dithranol (0.0625%, 1 times every night to maintain 12h) with the same effect, because of dithranol stimulation is obvious, with more love card berth three alcohol. Narrow wave UVB can also be u
31、sed in combination with Tazarotene Gel or oral vitamin A acid drugs. Schiener 14 believes that the card berth three alcohol (50 g/g) and 0.05% Tazarotene Gel ointment 1 times a day respectively with the combination of narrow band UVB for psoriasis, can significantly shorten the course of treatment.T
32、hree, 308nm excimer laser308nm excimer laser is a new type of ultraviolet light source in recent years. It has been used in the treatment of psoriasis, vitiligo and other skin diseases and has achieved remarkable curative effect. Compared with wide wave UVB and narrow wave UVB, the treatment is dire
33、ctly directed at psoriatic lesions without affecting normal skin, with less frequent treatment and less cumulative exposure and less carcinogenicity. 308nm excimer laser xenon chloride excimer laser can emit monochromatic pulse output, 30 x 10-9 second laser, up to 200Hz, easy to bend the light thro
34、ugh the optical fiber transmission to handle a 1.8 * 1.8cm2 spot, the energy of each pulse can reach 3mJ/cm2. 308nm excimer laser induced apoptosis of T cells was more obvious than narrow wave UVB, 15.In a study of 80 cases of open multi center patients with plaque psoriasis in 16, the initial amoun
35、t of 308nm excimer laser treatment is determined according to the MED, skin lesions, lesion thickness, lesion area, generally use the 3MED, around the ankle and rub skin lesions between 2MED, increase 1MED dark parts, increase the dose according to the the response to treatment, blisters after dose
36、reduction of 1 times (17%-50%) and the interval of 1 times after re irradiation, dose reduction of 1MED plaques become thin or pigmentation after (14-33%), keep the erythema, if the lesions had no obvious reaction dose increased by 1 MED. 2 times a week for 10 times in total, the 35% (28/80) in pati
37、ents with an average of 7.5 days after treatment was 90% remission, 72% (66/92) in patients with an average of 6.2 times after the treatment at least 75% lesions subsided, 84% patients after 10 or close to 10 times when treating lesions subsided 75%. Side effects include erythema, blisters, pigmenta
38、tion, and erosions, but the patient can tolerate it. The researchers believe that 308nm excimer laser only acts on the skin lesions, safe and effective, especially for patients with small skin lesions but poor response to general treatment. Recently Taneja17, an instrument for the treatment of 14 ca
39、ses of intractable psoriasis, the initial amount according to the modified PASI integral decision, 1 0.4 J/cm2, 2 0.6J/cm2, 3 J 0.9 /cm2, 2 times a week, up for 20 times, the results of 44 plaque treated 10 times on average (4-14) significantly subsided, and the CK was significantly improved (P 0.00
40、1), the mean cumulative dose of 8.8J/cm2 (2.2-22.8J/cm2), and side effects is only first times after the treatment of 2 cases of patients with mild burns, the study also found that before treatment with mineral oil can improve the penetration of 308nm excimer laser. Trehan 18 by excimer laser with h
41、igh dose of single treatment of 16 cases of patients with stable plaque psoriasis, each patient selected two patches, half of each plaque treated with 8MED or 16MED irradiation, the other half were given topical antibiotic cream and a gauze bag with 3 days after treatment. Results one month after tr
42、eatment in 11 cases of skin lesions improved significantly, 5 cases continued to improve in April, before the treatment of modified PASI integral average is 6.31, 4 weeks after treatment decreased to 3.56, there were 5 cases in the 4 month follow-up without recurrence and control plaque lesions, no
43、change. They then with moderate dose 3 times a week in the treatment of 15 cases of inactive plaque type psoriasis 19, each patient selected 6 patch treatment object, 1 plaques were determined according to MED irradiation dose, irradiation without itching or irritation symptoms, treatment again incr
44、eased dose of 25-30%, plaque thinning after dose not increase or only increased 1 times a week, such as blisters are topical antibiotic creams, blisters more after treatment. Results before treatment, the improved PASI scores averaged 7.5 (6.6-8.3), and the mean scores decreased by over 95%. The ave
45、rage number of treatments was 10.6 times, and the average cumulative dose was 6.1J/cm2 (1.9-18.3J/cm2). They believe that 3 doses of moderate doses per week can quickly eliminate plaque psoriasis, with fewer treatment times and cumulative doses, which are very tolerable.Four, PUVASince PUVA was used
46、 in the treatment of psoriasis in 1974, it has been widely used in clinic because of its high cure rate and less side effects compared with systemic drugs. The commonly used method is oral administration of 8-MOP0.5-0.8mg/kg solution, 1H or after 2H UVA irradiation,Or 2h after oral administration of
47、 5-MOP1.2mg/kg or 2h30min after irradiation with UVA. First months after the extinction of the skin, 2 times a week for second months, 1 times a week. Europe usually depends on the initial amount of MPD, and the United States often depends on the type of skin to determine the initial amount. PUVA is
48、 suitable for all types of psoriasis. Here are two European and American treatments that compare the efficacy of 20.Table 1 Evaluation of two multi center outcomes of psoriasis treated with PUVACategory Europe (1981), United States (1977)The initial dose of 1MPD is determined according to the type o
49、f skinWeekly exposure 42-3Dose increases were fixed according to individual differencesThe skin lesion clearance rate was 88.8%, 88%Irradiation times 2025Lesion resolution time (weeks) 5.7, 12.7The cumulative UVA dose (J/cm2) was 96245Because PUVA therapy produces skin pigmentation, erythema reaction, skin itching, nausea, vomiting, dizziness and other adverse reactions, long-term exposure can cause cataract, carcinogenic than other ultraviolet therapy