LEIDEN, The Netherlands – Sunlight can trigger exacerbations of systemic lupus erythematosus (SLE), but the long-wave ultraviolet A-1 (UVA-1, 340–400 nm) part of the light spectrum can reduce lupus disease activity, normalize some immune function in lupus patients, and should be considered for therapeutic use, Stan Pavel, MD, PhD, writes in an editorial in Rheumatology.¹ Dr. Pavel, of Leiden University Medical Centre in the Netherlands, argues that "UVA-1 phototherapy can be an effective and safe adjuvant therapy to the traditional pharmacological therapies in SLE patients."

Similar arguments were made last year by Hugh McGrath Jr, MD, of Louisiana State University Medical Center in New Orleans. Dr. McGrath reported normalization of anticardiolipin antibody levels, reversal of livedo reticularis, and improvement in Revised Systemic Lupus Activity Measure (SLAM-R) scores in a lupus patient after 8 months of twice-weekly UVA-1 treatment.² The patient's deteriorating cognitive function also stabilized.

Dr. Pavel had earlier reported a double-blind, placebo-controlled pilot study of UVA-1 in 12 SLE patients.³ Treatment significantly decreased the SLAM and SLE Disease Activity Index (SLEDAI) scores in the crossover study, while placebo treatment had no effect. He points out in his editorial that UVA-1 is absorbed by porphyrins and riboflavins, which are highly concentrated in mitochondria and might be the pathway for UVA-initiated apoptosis.

"Clinical experience with UVA-1 radiation shows that skin-infiltrating white blood cells are much more sensitive to UVA-1 than the epidermal cells," Dr. Pavel writes. "The UV-induced reduction in the number of infiltrating cells forms the basis of the therapeutic effect of UVA-1 in different dermatological conditions." He proposes that this effect on circulating blood components accounts for the systemic effects of UVA-1 in lupus.

Szegedi and colleagues⁴ document such a systemic effect, including a decrease in interferon-gamma-secreting CD4+ Th1 cells and CD8+ Tc1 cells in SLE patients treated with UVA-1 phototherapy. This was accompanied by significant improvements in SLEDAI scores, which the researchers attribute to the decrease in IFN-gamma-secreting cells and the decrease in Th1/Th2 and Tc1/Tc2 ratios after treatment.

Dr. Pavel thinks that phototherapy might be correcting the increased numbers of CD27 plasma cells that distinguish SLE patients with active disease from those with low disease activity. "We suggest that these abnormal cells may be one of the targets of UVA-1 therapy and that the irradiation might be able to suppress B-cell activity or induce the apoptosis of circulating activated B lymphocytes in the dermal blood vessels. In an in vitro model, we have recently shown a dose-related inhibition of immunoglobulin production and apoptosis of B cells by UVA-1 radiation," he writes.

Dr. Pavel's editorial follows close on the 103^rd anniversary of Niels Ryberg Finsen's Nobel Prize for the discovery that light therapy could treat skin tuberculosis, also known as lupus vulgaris. Although Dr. Finsen believed that shortwave ultraviolet radiation was the operative force in his treatment, Moller et al⁵ recently re-examined his technique and concluded that he was actually delivering light at wavelengths of 340–400 nm—the wavelength now thought to be beneficial in SLE.

Devices for administering therapeutic doses of UVA-1 are available in Europe but not yet in the US. However, the US Food and Drug Administration Office of Science and Technology conducted UVA-1 phototherapy studies in an SLE mouse model in 1997 "to prepare for future reviews of UVA-emitting tanning devices for such clinical applications."⁶

Some lupus patients are already taking things into their own hands. In 2004, journalist and lupus patient Anthony DeBartolo published Lupus Underground,⁷ a widely read book detailing his own interest in and construction of a UVA-1 device for less than $5000.

This approach is not without risk, however. Dr. Pavel warns, "It is absolutely essential that the irradiation apparatus used for the treatment of SLE patients does not emit short-wave (up to 340 nm) UV radiation.... UVB photons are much more biologically effective, and even a low dose of UVB could cause epidermal damage that could lead to the induction of antibody production."

References

1. Pavel S. Light therapy (with UVA01) for SLE patients: is it a good or bad idea? Rheumatology. 2006;45:653-655.

2. McGrath H. Elimination of anticardiolipin antibodies and cessation of cognitive decline in a UV-A1-irradiated systemic lupus erythematosus patient. Lupus. 2005;14:859-861.

3. 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.

4. Szegedi A, Simics E, Aleksza M, et al. Ultraviolet-A1 phototherapy modulates Th1/Th2 and Tc1/Tc2 balance in patients with systemic lupus erythematosus. Rheumatology. 2005;44:925-931.

5. Moller KI, Kongshoj B, Philipsen PA, et al. How Finsen's light cured lupus vulgaris. Photodermatol Photoimmunol Photomed. 2005;21:118-124.

6. Office of Science and Technology Annual Report, 1997. Available at: http://www.fda.gov/cdrh/ost/rpt97/OST1997AR19.html. Accessed June 5, 2006.

7. DeBartolo A. Lupus Underground: A Patient's Case for a Long-Ignored, Drug-Free, Non-Patentable, Counter-Intuitive Therapy That Actually Works – UVA1. Hyde Park Media; 2004.