Puvatherapy in the Management of Graft-Versus-Host Disease: Brazilian Experience.

Background: Graft-versus-host disease (GVHD) is a frequent late complication of allogeneic hematopoietic stem cell transplantation(HSCT) and remains a difficult problem to treat and manage. Therapy with 8-methoxypsoralen (8-MOP) and ultraviolet A to control drug resistant chronic graft-versus-host disease(c-GVHD) was based on the induction of functional changes in the effectors of the disease (T lymphocytes and cytokines). The potentially beneficial effect of phototherapy for treatment of cutaneous manifestations of GVHD led us to investigate retrospectively the effect of this therapy in a larger series of patients. Methods: From May 1991 to April 2005, 43 patients post-bone marrow transplanted for malignant and non-malignant diseases, with c-GVHD were treated with PUVA. Extensive c-GVHD was diagnosed in 39 patients and 4 patients had limited disease. PUVA was administered three times a week with no oral mucosa direct exposure. 8-MOP dose was 0.6mg/Kg given two hours before UVA irradiation and initial dose was based on skin type(Fitzpatrick). Results: From forty-three patients with resistant chronic graft-versus-host disease who were submitted to PUVAtherapy, three patients had began recently the treatment (less than 20 sessions) and were considered early to evaluated. Seven could not be evaluated because they had abandoned the treatment before complete 20 sessions. Early side effects were: nauseas, vomiting and gastric intolerance in 4 patients, burning in 6, photophobia in 2 and chronic effects were lentigo-PUVA in 1, guttate leukoderma in 1 and basal cell carcinoma in 1 patient. Immunosuppressive therapy was reduced in 7 patients and discontinued in 18 post-PUVAtherapy. Overall 25 patients(75,6%) responded to PUVA. Fifteen patients had complete response and 10 a partial response during PUVA treatment. Six patients(54,5%) from eleven had died from GVHD progression, during PUVAtherapy. The Kaplan-Meier estimate of survival at 3 years after the start of PUVAtherapy was 76%. Conclusion: PUVAtherapy was effective for tegumental c-GVHD resistant to immunosuppression, improving the quality of life of these patients. Evidence of systemic effect of PUVAtherapy could be observed by oral lesions healed in all patients without direct exposure.