Following early reports that a part of the ultraviolet A spectrum may have a positive immunomodulating effect in some inflammatory skin diseases, a new Dutch study has found that UVA-1 cold light therapy significantly decreases validated disease activity indices in patients with moderately active systemic lupus erythematosus (SLE) without causing significant adverse effects.

After 3 weeks of treatment, 12 patients who received UVA-1 cold light therapy had statistically significant decreases in both SLE Activity Measure (SLAM) (mean decrease of 4.8 points; P <.001) and SLE Disease Activity Index (SLEDAI) scores (P = .007) compared with placebo, according to team from the Departments of Medical Statistics and Rheumatology at the Leiden University Medical Centre, Leiden, The Netherlands.

One of 7 patients with known photosensitivity developed transient facial erythema, while another experienced a minimal activation of subacute, cutaneous lupus erythematosus (which disappeared with a reduction in light dose).

According to Hugh McGrath, Jr., MD, Professor of Medicine at Louisiana State University Health Sciences Center in New Orleans, the study confirms the utility and safety of irradiation as an adjunctive therapy for SLE, as suggested in a similar placebo-controlled trial of UVA-1 light therapy that he conducted in the 1990s.¹ "Irradiation decreased SLEDAI and SLAM scores, which is all we ask from any medication we study," he said.

The clinical SLE symptomatology that showed the most demonstrable improvement included arthritis (6 of 9 patients), myalgia/myositis (5 of 7), dyspnea (4 of 4), fatigue (4 of 11), headache (4 of 4), leukocyturia/erythrocyturia (4 of 7), and blood pressure (4 of 4).

Although UVA-1 light therapy is not FDA-approved for lupus, largely because no company has invested in producing the treatment lamps, Dr. McGrath described it as an accessible, nontoxic, gentle therapy. In addition, he has found anecdotally that patients who receive UVA-1 light therapy 3 times a week for 20 minutes often see enough of a reduction in disease activity to reduce exposure to once or twice a week, and eventually, can be completely weaned off of therapy. "I have one case study in which I found that UVA-1 light therapy reduces elevated anticardiolipin antibodies to normal," he said. "No other treatment, including corticosteroids, does that."

The Dutch team enrolled 12 patients (10 women, 2 men; ages 23-58 years) with moderately active SLE in a double-blind, placebo-controlled, crossover study. Participants were exposed to 12 J/cm² of UVA-1 cold light or placebo light 5 times a week for 3 weeks. After a 9-week washout period, patients were then crossed over to the other treatment.

At enrollment, the mean SLAM and SLEDAI scores were 13.42 (range 8-23) and 13.33 (range 6-23), respectively. Patients were taking a variety of drugs, including low-dose prednisone, azathioprine, antimalarial drugs, and nonsteroidal anti-inflammatory agents (NSAIDs). The researchers noted that apart from NSAIDs, patients were not permitted to change their medication during the course of the trial period.

CD27^high plasma cells, which are significantly correlated with SLE disease activity, may be targeted by UVA-1 light therapy, the investigators reported in Rheumatology.² They postulated that treatment may suppress B-cell activity or induce apoptosis of circulating activated B lymphocytes in the dermal and subcutaneous capillaries, thus lowering autoantibody production and lessening disease activity. They also suggested that B-cell/T-cell interaction might be affected by UVA-1 light therapy.

Dr. McGrath suggested that UVA-1 light therapy might be considered a benign early preemptive treatment—along with plaquenil and NSAIDs—for patients who present with lupus. "We now approach rheumatoid arthritis therapy in this way," he said. "As soon as a patient displays signs of RA, we put her on methotrexate or TNF-α [tumor necrosis factor-α] inhibitors. But we're still tip-toeing in lupus, when we really need to do a full body slam as we do with RA. This is a devastating disease and we shouldn't wait for it to declare." He noted that this "full-body slam" does not include corticosteroids, which he feels should be eliminated as a mainline therapy due to the risk of premature mortality.

References:

1. McGrath H, Martinez-Osuna P, Lee FA. Ultraviolet-A1 (340-400 nm) irradiation therapy in systemic lupus erythematosus. Lupus. 1996;5:269-274.
2. Polderman MCA, le Cessie S, Huizinga TWJ, Pavel S. Efficacy of UVA-1 cold light as an adjuvant therapy for systemic lupus erythematosus. Rheumatology. 2004;43:1402-1404.