374: PUVA Therapy for Acute Graft-Versus-Host Disease (GVHD) of the Skin

Glucocorticoids remain the standard for initial treatment of acute GVHD. However, toxicities and immunosuppression are severe and steroid-sparing strategies would be desirable. Between 5/96 and 4/07 we treated 55 patients with isolated skin GVHD with methoxsalen plus ultraviolet-A light therapy (PUVA), with the objective of avoiding systemic immunosuppressive therapy. Patients were treated with PUVA three times/week initially at doses of 0.25 J/m2, with exposure increased 0.25 J/m2 per treatment as clinically indicated. The median patient age was 48 (range 4–71) years. Twenty-six received a calcineurin inhibitor plus mycophenolate mofetil for GVHD prophylaxis, 24 received a calcineurin inhibitor plus methotrexate, and 5 received other regimens. Sixteen had related donors (1 HLA-mismatched), and 39 had unrelated donors (15 HLA-mismatched). The median onset of GVHD was 26 days after transplant, and the median start time of PUVA was 43 days. Forty-five patients received PUVA as initial therapy for acute GVHD, and 10 patients received PUVA for recurrent GVHD after discontinuation of prednisone administration. At the start of PUVA therapy, 31 patients (56%) had rash involving > 50% body surface area (BSA), 19 (35%) had rash 26–50% BSA and 5 (9%) had rash ≤ 25% BSA. The median number of PUVA treatments was 13 (range 2–26). Sixteen patients (29%) had complete responses after a median of 14 (range 8–26) PUVA treatments and required no subsequent systemic immunosuppressive therapy for treatment of acute GVHD. Twelve patients required systemic therapy after starting PUVA for treatment of isolated gastrointestinal GVHD, although 8 of these patients had cleared or improved skin rash before starting systemic therapy. Twenty-four patients (44%) required systemic immunosuppressive therapy after starting PUVA for treatment of skin GVHD (18) or skin plus gastrointestinal GVHD (6). Three patients had evidence of skin GVHD when PUVA was discontinued early due to readmission to the hospital or discharge home. Only four patients required secondary systemic therapy for treatment of acute GVHD. Thirty-one of 52 patients who could be evaluated developed chronic GVHD. Thirty-seven patients remain alive at a median of 753 days after transplant. Overall, 24 of 55 patients (44%) responded to PUVA with resolution or improvement of rash. These results suggest that PUVA can be effective in treating skin GVHD and in reducing the need for systemic immunosuppressive treatment.