A middle-aged woman consulted me for a rash on her palms and backs of hands for several years’ duration. The rash consisted of smooth pinkish-red bumps on the knuckles and rings and arcs on the palms with central clearing. Curiously, when the two palms were held together side-by-side, incomplete arcs formed a full circle. The previous Dermatologist’s skin biopsy showed granuloma annulare (please see my separate blog on this subject for more details). He treated her with various topical steroids to no avail.
Because the hands are amenable to treatment with ultraviolet light which has immunomodulating and anti-inflammatory effects, I decided to treat her with a Psoralen soak followed by exposure to UVA light. This treatment is called bath-PUVA. Bath-PUVA is usually used to treat psoriasis, but it is also on the list of alternative therapy for resistant cases of granuloma annulare. The soak with the dilute solution of psoralen lasts for about 15 minutes and serves to sensitize the skin to the UV light. Our initial exposure with UVA is 30 seconds; we treat twice per week and increase the dose by 8 seconds per side each treatment.
After 12 treatments, there was 50% improvement, and by 24 treatments, greater than 90% clearance was observed. We decided to stop the treatment at this point. Six weeks later, the palms were completely clear, and the knuckles showed 2 small dots.
About a month later, the patient was referred back by her Dermatologist for a different problem. The palms were still clear, but the soles were now red, thickened, and covered with white scales. Testing for fungus gave negative results. I performed a skin biopsy which confirmed psoriasis. We treated her soles with bath-PUVA, and she had an excellent response. She next developed patches of hair loss on the back of the scalp without any redness or scaling. The new diagnosis is Alopecia Areata. We have been treating this with local injections of triamcinolone, nearly all of the hair has regrown.
Comment: This patient had three different skin diseases most likely on the basis of autoimmunity. Autoimmune disease do tend to cluster in the same individual. The coexistence of granuloma annulare and psoriasis has been reported before. However, I believe this is the first case where bath-PUVA was used successfully to treat both diseases in the same patient. I have also seen psoriasis and alopecia areata in the same patient but never all three diagnoses together.
Bath-PUVA is an extremely safe treatment choice for palm and sole skin. The psoralen solution is so dilute that there is negligible absorption into the bloodstream. Therefore, while the palm and sole skin is made more sensitive to the UVA light, the rest of the body skin and eyes are not affected. The solution is simply washed off after the light exposure, and it is not necessary for the patient to wear sunglasses. It is uncommon to get a burn from bath-PUVA because the thickened skin is protective, and skin cancer has not been reported as a result of such treatment.
Other Interesting Case Studies:
Psoriasis Associated with Plaquenil (Hydroxychloroquine)
Painful Oral Erosions and White Patches