Therapy Eur J Dermatol 2009; 19 (5): 478-80

Selda Pelin KARTAL

DURMAZLAR
Treatment of acrodermatitis continua
Hatice AKPINAR with topical 8-methoxypsoralen plus local
Cemile EREN
Fatma ESKIOGLU narrowband ultraviolet B phototherapy
Semih TATLICAN

Department of Dermatology, Treatment of acrodermatitis continua of Hallopeau (ACH) is known to

Ministry of Health Ankara Diskapi Yildirim
Beyazit Education and Research Hospital,
Ankara, Turkey
Reprints: S.P. Kartal Durmazlar
<pelin@dr.com>
Article accepted on 7/4/2009
be difficult. A 24-year-old man presented with an 11-year history of
recurrent flares of painful pustular and scaly lesions on the distal por-
tion of his fingers and toes, with persistent nail dystrophy. Based on
the clinical and histopathological findings, ACH was diagnosed. The
patient was treated with topical 8-methoxypsoralen (8-MOP) without
occlusion, plus local narrowband ultraviolet B (NB-UVB) photother-
apy. The patient did not use any other medication between sessions
except topical emollients. Ten weeks later, when the patient had
received 20 sessions, almost all the lesions had cleared. We report
the first case of ACH which successfully responded to treatment with
8-MOP/NB-UVB.
Key words: acrodermatitis continua of Hallopeau, topical 8-
methoxypsoralen, narrowband ultraviolet B phototherapy

A
crodermatitis continua of Hallopeau (ACH) is a
rare, chronic disease characterized by pustular
eruptions predominantly involving the distal pha-
langes of the hands and feet with marked involvement of
the nail bed [1]. Atrophic skin changes, onychodystophy
and osteolysis are frequently present, causing painful and
disabling lesions [2]. ACH is generally considered as a
rare variant of pustular psoriasis, though some authors
classify it as a separate entity [3]. Treatment of ACH is
very difficult and often disappointing. Phototherapy is one
of the safest and most effective treatments for psoriasis
[4]. The use of narrowband ultraviolet B (NB-UVB)
phototherapy, with a peak emission wavelength at
311 nm, has been used for the treatment of psoriasis and
other inflammatory disorders for more than 20 years [5].
NB-UVB has been reported to be more effective than
broadband (BB) UVB [4] and as effective as systemic
psoralen plus UVA (PUVA) in psoriasis [5]. Topical 8-
methoxypsoralen (8-MOP) has been reported to enhance
the therapeutic results of targeted NB-UVB [6]. Topical 8-
MOP/NB-UVB has been used successfully to treat psori-
asis [7].
We describe a patient with ACH who responded to the
treatment of topical 8-MOP/NB-UVB successfully. To
the best of our knowledge, we report the first case of suc-
cessful treatment of ACH with topical 8-MOP/NB-UVB.
Case report
and ventral aspects of several fingers and dorsal aspect
of several toes, with associated nail dystrophy (figure 1).
There were no skin lesions elsewhere. Earlier treatment
had included topical antibiotics, antimycotics, potent cor-
ticosteroids, calcipotriol as well as methotrexate (15 mg/
week for one year at age 21) without any success. The
patient’s past medical history was otherwise unremarkable
and he had no personal or family history of psoriasis.
Clinical and microbiological examination gave no evi-
dence for bacterial or fungal infection. Histological fea-
tures of psoriasis were found in a biopsy specimen from
lesional skin. X-ray examination revealed no osteolytic
changes of the bones or joint deformities. Based on the
clinical and histopathological findings, ACH was diag-
nosed. Because of the disease progression, which led to
severe disability, the lack of response to previous treat-
ments, rejection of systemic medication by the patient
and in reference to a previous report on the successful
use in psoriasis [7], our patient was given twice weekly
local NB-UVB phototherapy with preceding 0.1% 8-MOP
over the lesional areas.
The photoelectrical device used in the treatment (Daavlin,
Bryan, OH, USA, 4356) had a local system with a hand
and foot unit and contained 8 lamps; 4 emitting UVA
(Voltarc F24T12/B4HO 16121) and the other 4 emitting
NB-UVB (Philips TL-01 20W/01RS). We used the device
only equipped with Philips TL-01 lamps and NB-UVB
was applied only in combination with topical 8-MOP.
doi: 10.1684/ejd.2009.0726

A proprietary formulation containing 0.1% MOP in a

A 24-year-old man presented with an 11-year history of
recurrent flares of painful pustular and scaly lesions on the
distal portion of fingers and toes, with persistent nail dys-
trophy. On examination, pustular and erythematosqua-
mous psoriasiform lesions were observed on the dorsal
hydrophilic water/oil emulsion (Vitpso 0.1% gel, Orva
pharmaceuticals, Izmir, Turkey) was applied 30 minutes
prior to irradiations without occlusion. The perilesional
area was protected with pure vaseline. The patient did
not use any other medication between sessions except top-
ical emollients. The minimal erythema dose (MED) deter-

478 EJD, vol. 19, n° 5, September-October 2009


A disease-related proinflammatory cytokines [11]. Unfortu-
B never been used to treat ACH.
Figure 1. The patient on presentation; pustular and erythema-
tosquamous psoriasiform lesions, skin atrophy, onychoptosis
and nail dystrophy of toes.
mined on gluteal areas of the patient was 300 mJ/cm2.
The initial dose was 70% of the MED. If erythema did
not occur, a dose increment of 40% was applied. If there
was erythema, a 20% dose increment was administered.
When more prominent erythema occurred, the dose was
not increased, instead it was reduced by a ratio of 1:2.
After reaching 2,000 mJ/cm2 the dose remained constant.
Already after the fifth session, the lesions responded to
the treatment (figure 2). Ten weeks later, when the patient
had received 20 sessions, almost all lesions had cleared
(figure 2) and the cumulative dose reached was
A B
Figure 2. Lesions after the 20th session.
EJD, vol. 19, n° 5, September-October 2009
18,359 mJ/cm2. Unfortunately, the patient was lost to
follow-up as he moved to another city.
Discussion
The treatment of ACH is known to be difficult. Lesions of
ACH are painful and disabling and associated with skin
atrophy, onycodystrophy and osteolysis. Histologically,
the characteristic feature of ACH is a subcorneal cavity
filled with polymorphonuclear neutrophils [8]. Because
of the histopathological similarity of ACH with pustular
psoriasis, it is generally accepted as a variant of localized
pustular psoriasis [1, 9, 10]. As high numbers of T lym-
phocytes and neutrophilic granulocytes infiltrating the
skin lesions play a major pathophysiological role in
ACH, most treatment regimens aim at downregulating the
nately, no therapeutic guidelines exist, only anecdotal
observations have been reported in the literature and
every successfully treatment of ACH contributes to the
therapeutic armamentarium [3, 9, 12]. For the treatment
of ACH, various topical and systemic agents, as well as
combined schemes, have been used. Topical treatments
such as corticosteroids, tar, dithranol, fluorouracil, calci-
potriol and calcineurin inhibitors have been used in com-
bination with systemic drugs or alone [11]. Retinoids,
cyclosporine, methotrexate, tetracycline, dapsone, colchi-
cine, anti-tumour necrosis factor-α (TNF-α) agents and
PUVA phototherapy have been reported as systemic ther-
apies [1-3, 8-12]. Topical 8-MOP/NB-UVB therapy has
NB-UVB phototherapy is an effective treatment for psori-
asis [13] and has been reported to be more effective than
BB-UVB [4] and as effective as PUVA therapy in psoria-
sis [5]. Because of the histopathological similarity of
ACH with psoriasis, among various treatment alternatives
we decided to give topical 8-MOP/NB-UVB phototherapy
in reference to the previous report on its successful use in
psoriasis [7]. In this report, topical 8-MOP/NB-UVB pho-
totherapy was applied once a week and fluencies of UVB
delivered to each spot were four multiples of MED and
remained constant throughout the study [7]. We applied
topical 8-MOP/NB-UVB phototherapy two times a
week, because the initial dose started was 70% of the
MED and our patient could attend the irradiation program
two times a week.
It has been shown that UVB primarily affects the T cells
in lesional skin of psoriasis [14]. However, UVB therapy
has also been shown to suppress lymphocyte production
by decreasing the production of proinflammatory cyto-
kines and by inducing the production of anti-
inflammatory cytokines within the lymph nodes [13].
UVB therapy has been proposed to have immunosuppres-
sive effects in psoriasis through induction of apoptosis in
T cells, and NB-UVB has been reported to be directly
cytotoxic to T cells in vivo, resulting in a higher depletion
of dermal and epidermal T cells in psoriatic skin [15]. It
has been shown that patients treated with NB-UVB
secreted interleukin-10 (IL-10), an anti-inflammatory
cytokine, and showed a markedly decreased production of
IL-1β, IL-2, IL-5 and IL-6 [13]. Treatment with recombi-
nant IL-10 has been reported to be effective in psoriasis
and UVB irradiation was shown to induce the production
479
of IL-10 both in human and murine skin [13]. IL-10 has
been demonstrated to inhibit the production of IL-1α, IL-
1β, IL-6, IL-8 and TNF-α by human monocytes [16]. It
was reported that the addition of topical 0.1% 8-MOP to
local NB-UVB significantly enhanced the therapeutic
effects of the light treatment without increasing the
adverse effects [7].
We reported a case with resistant ACH which responded
well to treatment with topical 8-MOP/NB-UVB. The ther-
apy was well tolerated and might be assumed as an effec-
tive treatment option for ACH. ■
Acknowledgements. Financial support: none. Conflict of
interest: none.
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