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PUVA and Malignant Melanoma
PUVA (ultraviolet A radiation plus oral methoxsalen) is a highly effective treatment for psoriasis but is associated with an increased risk of squamous cell carcinoma of the skin. PUVA also can lead to development of pigmented macules consisting of proliferations of large, cytologically atypical melanocytes.
To determine the relationship between long-term PUVA therapy and malignant melanoma, these investigators prospectively followed 1380 patients who started PUVA treatment in 1975 or 1976. The patients all were enrolled in the ongoing PUVA Follow-up Study, which assesses patients annually even if they have stopped PUVA therapy.
In the first 15 years (1975 to 1990), four melanomas were detected. This number is similar to the incidence expected in the overall population (relative risk, 1.1). However, from 1991 to 1996 seven new melanomas were detected. This is a statistically significant increase compared to that expected in the overall population (relative risk, 5.4). The risk of melanoma was higher in patients who received 250 treatments or more than in those who received fewer. No association between PUVA and a specific type of melanoma was detected.
Comment: These results support the concept of long-term, structured follow-up for new treatments that have carcinogenic potential. The real risk of melanoma from PUVA is not clear from this study because the number of patients was small and three of the melanomas occurred in one patient. The total dose of UVA was not reported; it may be more relevant than the number of treatments. Nevertheless, a clear message is that patients who have received PUVA therapy in the past should be cautioned about the risk and followed appropriately. Another message is that PUVA remains an option for therapy, but not for patients with any other risk factors for melanoma. Melanoma should be added to the list of risks associated with PUVA treatment.
— NH Shear
Published in Journal Watch Dermatology May 1, 1997
Citation(s):
Stern RS et al. Malignant melanoma in patients treated for psoriasis with methoxsalen (psoralen) and ultraviolet A radiation (PUVA). N Engl J Med 1997 336 1041-1045.
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