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O R I G I N A L A R T I C L E
Spectrophotometric intracutaneous analysis as an early non-invasive
predictor of efficacy in the phototherapy of psoriasisLjubomir Novakovic1, Symon Cotton2 & John L. M. Hawk1
1Photobiology Unit, St John’s Institute of Dermatology, St Thomas’ Hospital, London, UK, and 2Astron Clinica, Cambridge, UK
Key words:narrowband UVB; psoriasis; PUVA;
SIAscopy; spectrophotometric
intracutaneous analysis
Correspondence:Dr Ljubomir Novakovic, Photobiology Unit, St. John’s
Institute of Dermatology, St. Thomas’ Hospital,
Lambeth Palace Road, London SE1 7EH, UK.
Tel: 144 20 71886389
Fax:144 20 79281621
e-mail: [email protected]
Accepted for publication:5 November 2008
Conflicts of interest:None declared.
Summary
Background: Phototherapy is generally effective for psoriasis but individual responsiveness and
optimal treatment duration for disease clearance are unpredictable. However, easy, rapid and
non-invasive plaque assessment by spectrophotometric intracutaneous analysis (SIAscopy), a
novel multispectral skin imaging technique, may now make prediction feasible.
Objectives: The early prediction of psoriatic plaque clearance during phototherapy by
SIAscopy.
Methods: Sixteen psoriatic plaques in 10 psoriasis patients were serially assessed SIAscopically
during phototherapy for punctate dots representing the dilated papillary dermal blood
vessels characteristic of active psoriasis, and the results compared with the clinical findings.
Results: All plaques showing full SIAscopic clearance at early follow-up also showed complete
or almost complete clinical clearance, and remained the same thereafter. All showing no
SIAscopic clearance at early follow-up showed at most partial clinical clearance, and also
remained the same thereafter. All showing only partial SIAscopic clearance at early follow-up
also showed just partial clinical clearance, but then generally progressed to full SIAscopic and
clinical clearance.
Conclusions: SIAscopy of psoriatic plaques at early follow-up during patient phototherapy
enables good prediction of likely later clinical clearance, thereby potentially avoiding
unnecessary further treatment. A larger confirmatory study is now needed.
P soriasis, a chronic, hyperproliferative, immunological skin
disorder affecting 1–2% of the population worldwide, most
commonly demonstrates well-demarcated erythematous plaques
with adherent white or silvery scales. Histology typically shows
extended rete ridges and elongated dermal papillae containing
dilated and tortuous capillaries. Biopsy for such histology is
inconvenient, however, and these characteristic abnormalities
can now be identified easily and non-invasively instead by
spectrophotometric intracutaneous analysis (SIA), a novel
technique reliably able to identify so-called punctate dots
representing the typical psoriatic dilated capillary tips between
the broadened rete ridges (1) (Figs 1 and 2).
Phototherapy, whether narrowband UVB (NB-UVB) or
psoralen photochemotherapy (PUVA), is an excellent treatment
for 80–90% of psoriatic patients unresponsive to topical
treatments. However, the likely outcome of such therapy is
difficult to assess early on, unless perhaps by recurrent invasive
biopsy and histological assessment, but such an approach would
be inappropriate. Thus, phototherapy courses may become
unnecessarily long and expensive for patients, treatment staff
and treatment centres, increase the risk of patient skin ageing and
cancer, and delay patient transfer to other therapies. Therefore, an
easy, rapid, non-invasive technique permitting early, accurate
prediction of future therapeutic efficacy would be invaluable.
The SIAscope is a multispectral imaging device using the
specific absorptive and scattering properties in skin of molecular
radiation absorbers and larger structures, which interact uniquely
with light to form distinct remittance patterns over the
400–1000 nm waveband, thereby providing rapid, non-
invasive, in vivo information on gross skin structure and
pathology (2). As a result, epidermal and dermal pigment
distribution, lesional microcirculation patterns and volumes,
dermo-epidermal junction architecture, and dermal collagen
status may all be assessed, often enabling for example the
reliable diagnosis of malignant melanoma without the need for
biopsy (3). SIAscopic analysis takes about 10 s, 5 s to scan the
skin and 5 s for information processing.
SIAscope scans produce lesional colour images comparable to
those seen on dermoscopy, as well as maps, or SIAgraphs, of skin
collagen distribution, vascularity and melanin, compiled from
readings at about a million different lesional points. SIAgraphs of
normal and psoriatic skin respectively are shown in Figs 1 and 2,
the punctate dots on the psoriatic SIAgraph representing dermal
papillary vessel tips.
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P P P 4 1 1 B Dispatch: 11.12.08 Journal: PPP CE: Sonal/Guruprasad
Journal Name Manuscript No. Author Received: No. of pages: 5 Te: Bindu/mini
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Methods
To attempt to evaluate SIAscopic usefulness, this pilot study was
undertaken at St Thomas’ Hospital, London, UK. Approval for the
work was obtained from the St Thomas’ Hospital Ethics
Committee and 10 patients with widespread psoriasis, seven
undergoing phototherapy with NB-UVB and three with PUVA,
were imaged with the SIAscope before and during treatment for
punctate dots over either one or two plaques on the trunk or
upper limbs (Table 1). Psoriasis-unaffected areas in the same
patients were used as control sites. Exclusion criteria were pre-
vious phototherapy within the past 6 months and concomitant
systemic or topical treatment for psoriasis. Both NB-UVB and
PUVA were administered twice weekly. Patients were reviewed at
follow up at 4–6 weeks, then 8–12 weeks, when their psoriasis
overall was assessed clinically and the one or two previously
chosen plaques on the trunk or limbs independently evaluated
with the SIAscope.
Results (Table 1)
Sixteen psoriatic plaques in 10 patients with widespread psoriasis
were evaluated, either one or two in each patient. At initial
presentation, all 16 demonstrated punctate dots on SIAgraphy
but none at control non-affected sites. Seven were treated with
NB-UVB, two of these having two plaques assessed, and three
with PUVA, all having two plaques assessed (Table 1).
With respect to plaques, all five showing full SIAscopic
clearance (Fig. 3) at first follow-up at 4–6 weeks showed
complete or almost complete clinical clearance, and remained
the same, along with five others also now clear, at second follow-
up at 8–12 weeks. All three plaques showing no SIAscopic
clearance at first follow-up (Fig. 4) showed at most just some
clinical clearance, and again remained the same at second follow-
up. All seven plaques showing only partial SIAscopic clearance at
first follow-up (Fig. 5) showed just partial clinical clearance, as
did two still at second follow-up, the other five having now
progressed to full SIAscopic and clinical clearance. With respect
to patients, two showing full SIAscopic and clinical clearance in
one or two plaques, respectively, at first follow-up remained clear
at second follow-up, while another showing full SIAscopic but
just some clinical clearance in one plaque at first follow-up
showed continuing full SIAscopic but now complete clinical
clearance at second follow-up. One patient showing no
SIAscopic and just some clinical clearance at first follow-up still
showed no SIAscopic and just some clinical clearance at second
follow-up. Three patients showing partial SIAscopic and clinical
clearance in five plaques at first follow-up progressed to full
SIAscopic and complete or almost complete clinical clearance at
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Fig. 2. Spectrophotometric intracutaneous analysis (SIA) graph of
psoriasis-affected skin before phototherapy. Note the presence of many
punctate dots, some examples of which are indicated by arrows.
Fig. 1. Spectrophotometric intracutaneous analysis (SIA) graph of
normal skin. Note diffuse and regular distribution of haemoglobin.
r 2008 The Authors
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Table 1. Details of patients, and their numbers of plaques, plaque sites, treatments, SIAscope readings and degrees of clinical clearance during the study
PatientPlaquenumbers Location
PUVA orNB-UVB
First follow-up visit (4–6 Weeks) Second follow-up visit (8–12 Weeks)
SIAscope Clinical SIAscope Clinical
1 2 Trunk/upper arm NB-UVB F/F CC/CC F/F CC/CC2 1 Thigh NB-UVB N I N I
3 1 Thigh NB-UVB P I F CC
4 2 Upper arm/trunk NB-UVB P/F AC/AC P/F AC/CC
5 1 Trunk NB-UVB F CC F CC6 2 Trunk/trunk PUVA P/P I/I F/F AC/AC
7 2 Trunk/forearm NB-UVB P/P I/I F/F CC/CC
8 1 Trunk NB-UVB F I F CC9 2 Trunk/trunk PUVA N/P I/I N/P I/I
10 2 Trunk/trunk PUVA N/P I/I N/P I/I
Clinical evaluation:
CC, completely clear;
AC, almost clear;
I, improved.
SIAscope readings:
F, full clearance;
P, partial clearance;
N, no clearance.
Fig. 3. Spectrophotometric intracutaneous analysis (SIA) graph showing
full psoriasis clearance. Note the absence of punctate dots.
Fig. 4. Spectrophotometric intracutaneous analysis (SIA) graph showing
failure of psoriatic clearance following phototherapy. Note the persistent
punctate dots, some examples of which are indicated by arrows.
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second follow-up. One further patient with two plaques,
however, showed partial SIAscopic and clinical clearance in one
plaque and full SIAscopic and near full clinical clearance in the
other at first follow-up and remained essentially the same at
second follow-up, while a final two again showed partial
SIAscopic and clinical clearance in one plaque, but on this
occasion no SIAscopic and little clinical clearance in the other at
first follow-up, and again remained the same at second follow-
up. These results appeared independent of whether NB-UVB or
PUVA was used.
Discussion
SIAscopy was originally developed to help provide a reliable
diagnosis of malignant melanoma without the need for invasive
biopsy (3), but has gradually proved able to assess other
superficial cutaneous abnormalities also. Thus, we have shown
previously that the presence of punctate dots on SIAgraphs is
specific for psoriasis (1), a fact confirmed in the present study,
with all 16 psoriatic plaques having again demonstrated punctate
dots on SIAscopy before phototherapy.
The current study has also shown that SIAscopy may well
enable the avoidance of unnecessary phototherapy in
unresponsive patients, thus saving patient, staff and treatment
unit time and money, preventing long-term cumulative, adverse
radiation effects on patient skin and enabling early patient
transfer to other treatment. Thus, any patient with one or both
of two plaques showing full SIAscopic (and clinical) clearance,
and any with one or both of two plaques showing no SIAscopic
(or significant clinical) clearance at first follow-up at 4–6 weeks,
remained the same at second follow-up at 8–12 weeks, such that
phototherapy might have been terminated in these patients at
first follow-up. Any patient with one or both of two plaques
showing only partial SIAscopic (and clinical) clearance at first
follow-up progressed to full SIAscopic and also clinical clearance
at second follow-up, such that phototherapy should have been
continued at first follow-up in these patients. However, any
patient with each of two plaques showing different SIAscopic
(and clinical) appearances at first follow-up was less easily
assessible, but although the SIAscopically worse plaque at first
follow-up appeared to predict the eventual outcome best,
phototherapy should also have been continued in these patients
because of the predictive uncertainty.
Based on these various possible outcomes, therefore, a simple
but useful algorithm has been proposed by us for use at first
patient phototherapy follow-up at 4–6 weeks, and indicates
where continuation of the irradiation course might be
appropriate, or instead its termination with a change to other
therapy (Fig. 6).
Although this has only been a small study, such that the results
should only be considered preliminary, it seems likely, given that
the punctate dots which either disappeared on SIAscopy or are
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Fig. 5. Spectrophotometric intracutaneous analysis (SIA) graph of partial
clearance with phototherapy. Note the fewer punctate dots, some examples
of which are indicated by arrows, and the increased vessel numbers.
Fig. 6. Suggested algorithm to assist future treatment approach based on
SIAscopic assessment of psoriasis patients at first phototherapy follow up
at 4–6 weeks.
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not characteristic of active psoriasis, that the outcome of NB-UVB
or PUVA therapy in psoriasis may be predictable early in the
treatment course. Thus, all plaques clear at 4–6 weeks remained so
at 8–12 weeks, while none showing no clearance progressed any
further, suggesting these courses should have ceased forthwith.
Those showing partial clearance at 4–6 weeks nearly all progressed
to full clearance with continuing treatment, suggesting that
phototherapy should indeed have been continued in this group.
However, it is clear that several plaques from different body sites
rather than just one or two as in this study should be serially
assessed in all patients to give a more valid prediction of likely
patient response, and this is easily manageable, given that SIAscopy
is such a simple and rapid procedure.
A larger study evaluating more plaques in more patients is
now needed to confirm the encouraging findings produced by
this pilot study.
Summary statement
The rapid, easy, non-invasive procedure of SIAscopy is very likely
an important advance in predicting psoriatic phototherapeutic
efficacy, potentially permitting early treatment termination to
save time and money, minimize patient adverse effects, and
enable early initiation of other therapy. Thus, all patients in this
study with early SIAscopic and clinical clearance, and all with no
SIAscopic even if some clinical clearance, remained the same
thereafter, and could have stopped therapy early. Of those with
partial early SIAscopic and clinical clearance, nearly all progressed
to full clearance, such that they should also have carried on.
A larger confirmatory study is now needed.
References
1. Novakovic L, Hawk J. Spectrophotometric intracutaneous analy-
sis Q2: a novel technique in the differential diagnosis of psoriasis and
eczema. Br J Dermatol 2002; 147 (Suppl. 62): 104.
2. Cotton S. A non-invasive imaging system for assisting in the
diagnosis of malignant melanoma. PhD Thesis. Faculty of Science,
University of Birmingham, UK 1998.
3. Moncrieff M, Cotton S, Claridge E, Hall P. Spectrophotometric
intracutaneous analysis: a new technique for imaging pigmented
skin lesions. Br J Dermatol 2002; 146: 448–457.
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