Ac a De m Vene eol 95
CLINICAL REPORT
Ac a De m Vene eol 2015; 95: 579–582
© 2015 The Au ho s. doi: 10.2340/00015555-2028
Jou nal Compila ion © 2015 Ac a De ma o-Vene eologica. ISSN 0001-5555
Empowe ing helio he apy aims a clinical healing and
imp o ed coping wi h pso iasis and a opic de ma i is,
bu e idence o long- e m e ec s is sca ce. We s udied
he e ec o 2-week empowe ing helio he apy in he Ca-
na y Islands on clinical ou come and quali y o li e in 22
pso iasis and 13 a opic de ma i is pa ien s. Empowe -
men consis ed o mee ing pee s, sha ing expe iences
and pe o ming physical and men al p ac ices. Using he
sel -adminis e ed PASI (SAPASI) pso iasis was alle ia ed
s a is ically signi ican ly du ing helio he apy (p < 0.001),
and he ea men e ec was s ill de ec able 3 mon hs la-
e (p < 0.001). A opic de ma i is was imp o ed (p < 0.001)
when assessed wi h he pa ien -o ien ed SCORAD (PO-
SCORAD), and he e ec was s ill ob ious 3 mon hs la-
e (p = 0.002). Du ing helio he apy he de ma ology li e
quali y index (DLQI) imp o ed in bo h g oups (p < 0.001),
pe sis ing in a opic pa ien s o up o 3 mon hs (p = 0.002),
bu no in pso iasis pa ien s. In conclusion, a 2-week em-
powe ed helio he apy showed a long-las ing imp o emen
in pso iasis and a opic de ma i is disease ac i i y, and also
in he quali y o li e o a opic pa ien s. Key wo ds: i amin
D; ul a iole B adia ion; SAPASI; PO-SCORAD; DLQI.
Accep ed Dec 3, 2014; Epub ahead o p in Dec 4, 2014
Ac a De m Vene eol 2015; 95: 579–582.
Toni Ka ppinen, Depa men o De ma ology, Päijä -Häme
Cen al Hospi al, Keskussai aalanka u 7, FIN-15850 Lah i,
Finland. E-mail: [email p o ec ed]
Pso iasis (PS) and a opic de ma i is (AD) a e ch onic
in lamma o y skin diseases wi h a nega i e impac on
quali y o li e (QoL) (1, 2). PS and AD can be ea ed
wi h sunba hing, i.e. helio he apy (HT), alle ia ing he
physical and psychological a igue o pa ien s (3–5). The
No dic heal h au ho i ies ha e unded
HT cou ses since he 1970s (5, 6).
Recen ly, emphasis has mo ed om
HT o empowe men o pa ien s and
coping wi h he disease. The e o e,
HT was eno a ed o mee hese go-
als. The p esen HT model consis s o
mee ing pee s, sha ing expe iences,
adop ing a heal hy li e s yle, exe ci-
sing p ac ices, imp o ing physical,
psychological and social wellbeing and coping wi h he
disease guided by heal h ca e expe s. The s a consis s
o expe ienced nu ses, a physio he apis and a psycholo-
gis . Because less emphasis is pu on HT, he ea men
esul s could di e om hose o adi ional HT.
To ou knowledge, no ea lie s udy has assessed
sunba hing habi s, QoL o i amin D (VD) changes in
pa allel o PS and AD pa ien s ecei ing HT. The aim
o he s udy was o moni o he e icacy o a 2-week
empowe ed HT on pe sonal UV exposu e, clinical
ou come, QoL and VD balance in PS and AD pa ien s
a ending he same cou se. We also pe o med a ollow-
up 3 mon hs a e he HT cou se.
MATERIAL AND METHODS
Pa ien s and helio he apy cou se
The Finnish Pso iasis Associa ion and he Finnish Cen al O ga-
nisa ion o Skin Pa ien s oge he a anged a 2-week HT cou se
o PS and AD pa ien s in Pue o Rico (27°N, 15°W), he Cana y
Islands, Spain om 27 h Oc obe o 10 h No embe in 2012. Inclu-
sion c i e ia we e pso iasis o a opic de ma i is wi hou demanding
any minimum se e i y sco ings, subjec s had o be aged 18 o
olde and ha e a e e al om a doc o . Exclusion c i e ia we e
pho osensi i i y, Fi zpa ick’s skin pho o- ype I, pho osensi ising
d ugs, excessi e alcohol use, d ug abuse, se e e ca dio ascula
diseases, unbalanced diabe es o men al diso de s (7). The cou se
included an educa ion day be o e HT and a eunion weekend 3
mon hs a e wa ds. The amoun o be paid by he pa icipan s was
€400, he o al cos pe pa ien being €2,450. Twen y- wo PS and
13 AD pa ien s ook pa in he s udy (Table I). Fi een pa ien s
had pso ia ic a h i is and 5 o hem used biologic d ugs, 3 o hese
pa ien s also used me ho exa e. Two pa ien s had me ho exa e
as a mono he apy. Du ing HT he pa ien s we e allowed o use
hei ou ine opical medica ion. Nine een pa ien s (14 PS, 5 AD)
used VD supplemen a ion be o e HT, on mean 23 µg ( ange 5–50
µg) daily, bu no du ing HT o 3 mon hs a e i .
The pa ien s had hei sunba hing plans adjus ed o hei
Fi zpa ick’s skin ypes. The i s sola exposu e imes anged
Empowe ing Helio he apy Imp o es Clinical Ou come and Quali y
o Li e o Pso iasis and A opic De ma i is Pa ien s
Toni KARPPINEN1,2, Lasse YLIANTTILA3, Hannu KAUTIAINEN4, Timo REUNALA1 and E na SNELLMAN1,5
1Medical School, Uni e si y o Tampe e, Tampe e, 2Depa men o De ma ology, Päijä -Häme Cen al Hospi al, Lah i, 3Radia ion and Nuclea Sa e y Au-
ho i y, Helsinki, 4Uni o P ima y Heal h Ca e, Helsinki Uni e si y Cen al Hospi al and Uni o P ima y Heal h Ca e, Kuopio Uni e si y Hospi al, Helsinki
and Kuopio, and 5Depa men o De ma ology, Tampe e Uni e si y Hospi al, Tampe e, Finland
Table I. Demog aphics o pa ien s wi h pso iasis and a opic de ma i is (AD), and UV
adia ion doses ecei ed du ing a wo-week helio he apy cou se
Pso iasis (n = 22) AD (n = 13) p- alue
Male/Female, n8/14 0/13 0.013
Age, yea s, mean ± SD ( ange) 52 ± 10 (34–68) 44 ± 17 (21–74) 0.069
Body mass index, mean ± SD ( ange) 28.2 ± 6.2 (17.1–41.9) 27.1 ± 6.9 (19.1–39.8) 0.643
Fi zpa ick’s skin ype, II/III/IV 6/15/1 5/8/0 0.615
UV dosime e (SED), mean ± SD ( ange) 30 ± 16 (22.4–38.5)a43 ± 16 (32.1–53.9)b0.062
aF om 18 pa ien s, bF om 12 pa ien s. SED: s anda d e y hema dose.
580 T. Ka ppinen e al.
om 20–90 min o PS and 15–30 min o AD pa ien s. Bo h
sides o he body we e exposed du ing sunba hing. The ime was
inc eased wi hin a week o 90–300 min o PS and o 120 min
o AD pa ien s. The scheduled sunba hing ea men s we e done
wi hou sunsc een in he mo nings o a e noons. Sunsc een was
applied libe ally he ea e . The suppo ing p og am included
eaching sel -managemen and a heal hy li e s yle as well as g oup
con e sa ions wi h a psychologis , al oge he o 14 h o bo h
g oups. Physical exe cise included wa e spo s, ekking and
gymnas ics o 24 h o he PS g oup and 11 h o he AD g oup.
The E hics Commi ee o he Tampe e Uni e si y Hospi al
app o ed he s udy p o ocol. All pa ien s ga e hei in o med
consen be o e he s udy.
UV exposu e measu emen s
To measu e he pe sonal UVB dose ecei ed by he skin du ing
HT he pa ien s wo e pe sonal UV dosime e s (VioSpo blue line
Type III, BioSense, Bo nheim, Ge many), one me e was used o
week one and ano he o week wo (8, 9). The me e s de ec a
dose anging om 1.5 o 90 S anda d E y hema Dose (SED). The
dosime e s we e a ached o he pa ien s’ uppe a ms o w is s wi h
s aps and du ing sunba hing hey we e placed on owels beside
he pa ien s (10). Eigh een PS and 12 AD pa ien s wo e dosime-
e s. The ambien maximum sola UV-i adiance was measu ed
as a mean dose om 2 VioSpo Type III dosime e s a a ime.
The me e s we e pu in an open place and eplaced e e y o he
day o a oid o e exposu e. The Spanish Agency o Me e eology
(Agencia Es a al de Me e eologica; www.aeme .es) supplied he
global sola UV i adiance da a om he nea by (dis ance 15 km)
Maspalomas C. Insula Tu ismo wea he s a ion. The i s HT
week was ainy and cloudy and he second HT week was sunny.
Du ing he HT maximum UV index a ied be ween 5 and 8.
Assessmen o disease ac i i y
The PS pa ien s illed ou he Sel -Adminis e ed Pso iasis
A ea and Se e i y Index (SAPASI) and AD pa ien s he Pa ien
O ien ed Sco ing o A opic De ma i is (PO-SCORAD) o ol-
low he disease ac i i y (11, 12). Disease se e i y and p u i us
we e assessed globally using he Visual Analogue Scale (VAS)
(13). The De ma ology Li e Quali y Index (DLQI) was used
o assess he change in he QoL (14). All measu es we e illed
ou 3 imes: a he onse , a he end and 3 mon hs a e HT.
Se um 25-hyd oxy i amin D measu emen s
VD samples we e aken immedia ely be o e, a he end and
3 mon hs a e HT. The se a we e deep- ozen and s o ed a
–20°C. Analysis o 25-hyd oxyVD was pe o med in duplica es
using adioimmunoassay (Immunodiagnos ic Sys ems, Boldon,
UK), as desc ibed ea lie (15).
S a is ics
The da a a e p esen ed as means wi h s anda d de ia ions (SD) o
as coun s wi h pe cen ages. Con idence in e als (95% CI) we e
ob ained by bias-co ec ed boo s apping (5,000 eplica ions)
S a is ical compa isons we e made by using analysis o - es , co-
a iance (ANCOVA). In he case o iola ion o he assump ions
(e.g. non-no mali y), a boo s ap ype es was used. Longi udinal
measu es o con inuous ou comes we e analysed using a boo s ap
ype gene alised es ima ing equa ions (GEE) model. GEE we e
de eloped as an ex ension o he gene al linea model o analyse
longi udinal and o he co ela ed da a. GEE models ake in o ac-
coun he co ela ion be ween epea ed measu emen s in he same
subjec ; models do no equi e comple e da a and can be i e en
when he e a e no obse a ions a all ime-poin s o indi iduals.
No adjus men was made o mul iple es ing. When compa ing
inc eases in VD concen a ions, he model was s anda dised by age,
sex and body mass index (BMI). Pea son’s χ2 es was used when
compa ing nominal da a. The STATA 13.1, S a aCo p LP (College
S a ion, TX, USA) s a is ical package was used o he analyses.
RESULTS
UV exposu es du ing helio he apy
Acco ding o pe sonal dosime e measu emen s he PS
pa ien s ecei ed a mean UV dose o 30 ± 16 SED and
he AD pa ien s 43 ± 16 SED du ing HT (Table I) show-
ing no signi ican di e ence (p = 0.062). The espec i e
cumula i e ambien wo-week UV i adiance was 244
SED measu ed by VioSpo III dosime e s and 303 SED
using he UV eco ds ob ained om he Maspalomas
C. Insula Tu ismo s a ion.
Disease ac i i y and quali y o li e a he end o helio he apy
HT was s a is ically equally e ec i e in PS and AD
when disease ac i i y was sco ed (Table II). Mean
SAPASI dec eased om 6.7 by 4.9 uni s (p < 0.001) and
PO-SCORAD om 30.6 by 19.5 uni s (p < 0.001). Fou
Table II. Clinical ou come o a wo-week helio he apy cou se in pa ien s wi h pso iasis and a opic de ma i is (AD) measu ed by Sel -
Adminis e ed Pso iasis A ea and Se e i y Index (SAPASI) o PO SCORAD sco es, and by isual analogue sco es o se e i y and p u i us.
Vi amin D concen a ions we e measu ed a he same ime poin s as he clinical ou come sco es. Mean
± SD and change (Δ) o  mean
alue compa ed o Day 0
Pso iasis (n = 22) AD (n =13)
Day 0 Δ Week 2 Δ Week 14 Day 0 Δ Week 2 Δ Week 14
SAPASI/PO SCORAD (95% CI) 6.7 ± 5.6
(4.2–9.2)
–4.9***
(–6.8 o –3.0)
–3.1***
(–4.7 o –1.4)
30.6 ± 17.6
(20.0–41.3)
–19.5***
(–26.2 o –12.9)
–10.0**
(–16.3 o –3.8)
Visual analogue sco e global (95% CI) 3.9 ± 2.2
(2.9–4.9)
–2.0***
(–2.8 o –1.0)
–1.4**
(–2.3 o –0.4)
3.4 ± 2.2
(2.1–4.7)
–1.8***
(–2.4 o –1.2)
–0.9
(–2.0–0.2)
Visual analogue sco e p u i us (95% CI) 3.1 ± 2.2
(2.1–4.1)
–2.2***
(–3.1 o –1.4)
–0.9
(–1.9–0.1)
3.7 ± 2.5
(2.2–5.3)
–2.2***
(–3.1 o –1.4)
–0.9
(–2.3–0.4)
De ma ology Li e Quali y Index (95% CI) 6.1 ± 3.3
(4.7–7.6)
–4.3***
(–5.5 o –3.1)
–0.8
(–2.8–1.2)
7.2 ± 4.8
(4.3–10.0)
–5.3***
(–7.3 o–3.4)
–3.2**
(–5.2 o –1.2)
Vi amin D, nmol l–1 (95% CI) 86.6 ± 20.0
(77.8–95.5)
13.8***
(8.6–19.0)
0.4a
(–5.2–6.8)
84.1 ± 16.0b
(73.4–94.9)
20.5***
(14.0–25.6)
–3.1c
(–10.0–4.0)
**p < 0.01, ***p < 0.001 compa ed o helio he apy day 0 alues.
a20 pa ien s; b11 pa ien s; c10 pa ien s.
Ac a De m Vene eol 95
581
Empowe ing helio he apy imp o es symp oms o pso iasis and a opic de ma i is
PS bu none o he AD pa ien s expe ienced comple e
clea ance, and 75% clea ance was seen in 13 (59%) PS
and 2 (15%) AD pa ien s. Using he VAS scales he e
was signi ican imp o emen in disease se e i y and
p u i us in bo h g oups (Table II). QoL was imp o ed
showing a dec ease in mean DLQI sco e om 6.1 by
4.3 uni s (p < 0.001) in PS pa ien s and om 7.2 by 5.3
uni s (p < 0.001) in AD pa ien s (Table II). A onse o
HT no PS o AD pa ien was VD-insu icien , de ined
as 25(OH)D3 < 50 nmol l
–1
. Du ing HT he VD con-
cen a ions inc eased signi ican ly (p < 0.001, Table II)
and equally (p = 0.56) in bo h pa ien g oups.
Disease ac i i y and quali y o li e a e helio he apy
A he ollow-up 3 mon hs a e HT, he ea men e ec
signi ican ly pe sis ed when compa ed o ini ial sco es
(Table II). The dec ease in SAPASI was 3.1 (p < 0.001)
and in PO-SCORAD 10.0 (p = 0.002). Using he VAS
he global disease se e i y also emained dec eased
(p = 0.004) in PS pa ien s bu no (p = 0.11) in AD pa ien s.
The VAS sco es depic ing p u i us had e u ned close o
baseline le els bo h in PS (p = 0.058) and AD (p = 0.17)
pa ien s (Table II). In PS pa ien s he 3-mon h ollow-up
DLQI sco es had d opped o baseline (p = 0.43), bu in
he AD pa ien s i emained imp o ed (p = 0.002) (Table
II). The VD concen a ions had dec eased in bo h he PS
and AD pa ien s close o he p e-HT alues (Table II).
DISCUSSION
The esul s showed PS o imp o e s a is ically highly
signi ican ly du ing empowe ing HT, he mean SAPASI
educing by 73%. Comple e clea ance was eached in
18% and 75% SAPASI clea ance in 59% o he pa ien s.
The mean ini ial SAPASI sco e o 6.7 was ma kedly lo-
we compa ed o he PASI o SAPASI sco es o p e ious
s udies (16–19) indica ing a mild disease, bu 7 pa ien s
we e using sys emic d ugs. Use o me ho exa e o bio-
logic d ugs should howe e no dampen he e ec o HT
since bo h ha e syne gis ic e ec s wi h UVB i adia-
ion (20, 21). HT educed he PS sco ings only sligh ly,
which could be due o he sho du a ion o HT, o he
insensi i i y o SAPASI as ega ds a mild disease s a e.
In a s udy by Wahl e al. (17) he mean SAPASI emained
dec eased by 21.1% 4 mon hs a e HT, whe eas in ou
s udy he educ ion was 46.3% a he 3-mon h ollow-up
isi . I is no known whe he he pe sis ing imp o emen
o he SAPASI in ou pa ien s was due o he enhanced
educa i e con en s o he cou se.
In AD pa ien s he mean PO-SCORAD sco e imp o-
ed s a is ically signi ican ly om 30.6 o 11.1 bu did
no show comple e clea ance in any o he pa ien s, and
only 15% eached 75% clea ance. SAPASI and PO-
SCORAD a e no compa able wi h each o he , because
PO-SCORAD includes subjec i e pa ame e s in addi ion
o isible signs. A he end o HT he e we e pa ien s wi h
no isible eczema, bu due o p u i us o sleep dis u ban-
ces he PO-SCORAD did no show comple e clea ance.
We used he DLQI measu e o make a pa allel as-
sessmen o he QoL o bo h PS and AD pa ien s. The
imp o emen o QoL in he AD pa ien s seemed o be
mo e long-las ing han in he PS pa ien s, bu di ec
be ween-g oups compa isons a e no jus i ied due o
limi ed sample size in his s udy (22, 23). The PS and
AD pa ien g oups also di e ed signi ican ly o gende
(p = 0.013), and he e we e only emales in he AD g oup.
This could ha e in luenced he esul s, because women
ha e been shown o comply be e wi h opical ea men s
han men (24). In his s udy, he size o he g oup as well
as inclusion and se e i y o he pa ien s we e in he hands
o he pa ien associa ions depic ing he eal li e si ua-
ion, a he han a s ic expe imen al esea ch p o ocol.
The pe sis en long- e m (up o 3-mon h) s a is ically
signi ican imp o emen o DLQI among AD pa ien s
su p ised us, because his con adic ed he VAS sco es
measu ing disease se e i y and p u i us. The VAS sco es
had e u ned o baseline. This disc epancy could be due o
p u i us a ec ing he QoL o a opic pa ien s mo e han he
DLQI sco es can show. I is impo an o use mo e han
one measu e in pa allel o inc ease eliabili y. An in e-
es ing measu e, which we un o una ely we e no awa e
o ea lie , is he Heal h Educa ion Impac Ques ionnai e
(25). This was used in a ecen ly published s udy o Wahl
e al. (25), howe e also in his s udy he educa ional
impac o empowe ing HT was a challenge (25).
PS pa ien s could be mo e isk- aking and p one o
highe UV doses han AD pa ien s (26, 27), bu i u ned
ou ha AD pa ien s ecei ed a highe dose in ewe
hou s. This could be explained by he di e en ou doo
ac i i ies o he g oups (28). Ambien i adiance is also
highly dependen on he season. This became ob ious
in ou ea lie s udy whe e he pe sonal UV dosime e
exposu es o AD pa ien s on wo-week HT we e 75 SED
in Janua y and 131 SED in Ma ch
(9). The 30 SED and
43 SED UV doses o ou PS and AD pa ien s e lec bo h
he lowe UV index o No embe season and un o una e
wea he condi ions o he i s HT week, which p obably
a ec ed he clea ance o he skin diseases.
No pa ien was VD insu icien a he onse (Table II).
Despi e his, HT imp o ed he VD s a us s a is ically
signi ican ly in bo h pa ien g oups, 13.8 nmol l
–1
o PS
and 20.5 nmol l
–1
o AD ha ing ecei ed on mean 30
SED and 43 SED espec i ely. Sunligh seems o be a
e y po en VD induc o e en in subjec s who showed
no VD de iciency.
The empowe ing HT model is a esponse o public
p essu es s essing pa ien s’ own esponsibili y and
sel -managemen o hei ca e. New cou ses un by
he pa ien o ganisa ions ocus mo e on empowe men
han clea ance o he disease. Wahl e al. (25) s udied
he e ec o clima e he apy on sel -managemen in
PS pa ien s, and ou s udy ocused also on AD pa-
Ac a De m Vene eol 95
582 T. Ka ppinen e al.
ien s showing ha bo h PS and AD we e s a is ically
signi ican ly imp o ed (25). In ou pas s udy HT was
ega ded cos -e ec i e o he high indi ec cos s only
o pa ien s wi h se e e pso iasis (29). Simila o he
No wegian s udy (25) we we e unable o con i m long-
e m imp o emen o QoL in PS pa ien s (25).
To conclude, UV doses ecei ed by PS and AD pa-
ien s we e compa able showing no ob ious di e en-
ces. The empowe ing HT clea ed he skin symp oms
s a is ically signi ican ly, bu in he long un did no
imp o e he QoL o PS pa ien s. In PS pa ien s he
dec ease in disease se e i y exp essed using he VAS
seemed mo e long-las ing han in AD pa ien s. A wo-
week HT imp o ed VD s a us s a is ically signi ican ly
e en in non-VD de icien and subs i u ed indi iduals.
ACKNOWLEDGEMENTS
We hank he Finnish Pso iasis Associa ion and he Finnish
Cen al O ganisa ion o Skin Pa ien s o hei collabo a ion in
his s udy. We also hank he Spanish Agency o Me e eology
o he egional UV adia ion da a.
Funding sou ces: The Compe i i e S a e Resea ch Financing o
he Expe Responsibili y A ea o Tampe e Uni e si y Hospi al.
The au ho s decla e no con lic o in e es .
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