Low Dose Psoralen Plus Ultraviolet A (PUVA) Is an Effective and Safe Method for the Treatment of Chronic Graft Versus Host Disease

Chronic graft versus host disease (ch.GVHD) is the most frequent late complication after allogenic stem-cell transplantation. Systemic immunosuppressive agents are usually required to control the disease. Psoralen plus UVA (PUVA) has been used for the treatment of ch.GVHD with variable beneficial effects. The objective of this study was to assess the efficacy and safety of a relatively lower dose of oral psoralen compared with previous reports, for the treatment of ch.GVHD patients with PUVA. Eleven patients who received allogenic bone marrow transplantation and had severe progressive ch.GVHD that was unresponsive to conventional immunosuppressive treatments were treated with oral 8-methoxypsoralen (0.2 mg/kg, up to 10 mg) two hours before exposure to UVA. The patients received a median of 43 treatments (range: 18 to 72). Mean cumulative dose of UVA was 200.5 J/cm2 (range, 116.5-306.5 J/cm2). In four of the 11 patients, there was a complete resolution of cutaneous ch.GVHD and the remaining seven patients achieved partial response with PUVA treatment. Complete and partial remission was observed in four and six patients with lichenoid lesions, respectively, but all of the four patients with sclerodermoid GVHD showed partial response to PUVA treatment. We observed no side effects like phototoxicity, nausea and vomiting, and exacerbation of GVHD. Liver enzymes raised in five patients, causing no significant morbidity for them. Low-dose psoralen plus UVA can be a safe and effective therapy for chronic cutaneous GVHD. Although the number of treatments and total cumulative exposure to UVA was rather high in our study, we observed no phototoxic reaction or severe irreversible liver damage due to phototherapy, which may be because of a relatively lower dose of methoxsalen used in our patients. Psoralen plus UVA is effective particularly in lichenoid GVHD lesions but sclerodermoid lesions may also benefit from this therapy.