DR [page 8] [Dermatology Reports 2012; 4:e3] Psoralen plus ultraviolet A (PUVA) soaks and UVB TL01 treatment for chronic hand dermatoses Lisbeth Jensen, Anette Stensgaard, Klaus Ejner Andersen Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark Abstract Chronic eczematous hand dermatoses with and without contact allergies are complex dis- eases, which makes it a challenge to select the best treatment and obtain an optimal patient experience and a satisfactory treatment result. The aim of this study was to evaluate retrospec- tively the clinical effect and patient experience of local treatment with psoralen plus ultraviolet A (PUVA) soaks and TL01 phototherapy for severe chronic hand dermatoses, and also to evaluate the quality of life for the subgroup of patients with allergic contact dermatitis includ- ing Compositae allergy. A retrospective evalua- tion of results for 94 consecutive patients hav- ing received a total of 121 treatment courses with local PUVA soaks or TL01 phototherapy for one of the following diagnoses (n=number of treatment courses): psoriasis (n=19), hyperk- eratotic hand eczema (n=27), Pustulosis Palmoplantaris (PPP) (n=22), vesicular eczema (n=16), Compositae dermatitis (n=24), and allergic contact dermatitis (n=13). Moreover, semi-structured interviews with 6 selected patients having multiple contact aller- gies including Compositae allergy were used to evaluate quality of life. As a result, we found that PUVA soaks has good effect in patients with psoriasis and hyperkeratotic hand eczema and local phototherapy for chronic hand der- matoses is a useful treatment option in select- ed cases. Introduction Chronic hand dermatoses, including eczema, psoriasis and palmar pustulosis are common, difficult to treat, and have a high impact on patients’ quality of life. In Scandinavia the 1 year prevalence of hand eczema is 10-14%.1,2 In spite of this only few and small treatment studies have been per- formed to document treatment effect. One explanation for the limited number of high quality treatment studies is the lack of agree- ment on classification of hand dermatoses and the fluctuation of disease severity.1 Photo - therapy is one treatment option used with questionable results. Sezer and co-workers evaluated local (pso- ralen plus ultraviolet A) PUVA (administered as paint) compared to TL01 in patients with chronic hand dermatoses. The results showed that PUVA worked best in patients with PPP, and in patients with chronic hand eczema (dry and dyshidrotic) both treatment modalities had beneficial effect. Patients were assessed at week 0, 3, 6, 9 and 10 weeks after the last treatment, and 21 of 25 and 12 of 15 patients completed the studies respectively.3,4 In an older study PUVA soaks (8-Methoxypsoralen) were given to 80 patients over a 5 year period; 56 patients completed the study, of these 16 (29%) cleared more than 90%.5 For nine years UVB TL01 and PUVA soaks (Trioxysalen) have been available as treatment modalities at the Department of Dermatology, Odense University Hospital for severe hand der- matoses. The treatment modalities were options for patients with difficult to treat der- matoses at the discretion of the dermatologist. According to the Danish Contact Dermatitis Group hand eczema may turn into a chronic disease, if the patient is not offered examina- tion, guidance and treatment within the first 3 months.6 A study by Lerbaek et al. found that 68% (96/142) still suffer from hand eczema at a follow up study 8 years later.7 Other studies show if the patient has got one contact allergy, his risk of getting more contact allergies, a more severe hand eczema and a worse progno- sis is increased.8,9 Agner et al. found that patients allergic to Compositae and rubber chemicals had the most severe hand eczema, and patients allergic to Compositae, cobolt or paraphenylendiamine (PPD) had the lowest quality of life.9 This suggested that patients allergic to Compositae had the worst hand eczema and their life quality is severely affect- ed. In another study, 2 patients allergic to Compositae were treated with PUVA (sys- temic) together with systemic Prednisolone to be able to tolerate the phototherapy and both needed maintenance treatment to prevent flares.10 Hand eczema can have a great influ- ence on patients’ life and quality of life because of the physical, psychological and social consequences.11,12 This study evaluated retrospectively the experience and effect of PUVA soaks and TL01 phototherapy for the treatment of severe chronic hand dermatoses with the purpose to reveal the beneficial effects in balance with the duration of effect and resources involved in performance of the treatment. Further, a sub- group of patients suffering from multiple con- tact allergies and Compositae allergy was inter- viewed to explore how their quality of life was influenced by the allergies and hand eczema in order to optimize the service provided by health professionals (Table 1). Materials and Methods A retrospective quantitative evaluation of the records of patients who in the years 2008- 2010 had received a minimum of 10 treatments in one course13 for treatment of one of the fol- lowing diagnoses: Psoriasis, hyperkeratotic eczema, PPP, vesicular eczema, Compositae dermatitis, and allergic contact dermatitis. All patients also received topical treatment with varying amounts of topical corticosteroids and moisturisers with inadequate effect, therefore phototherapy was added as supplement. Psoralen plus ultraviolet A soak The patient placed hands for 10 min in 2 L water of 37°C mixed with 1.0 mL Tripsor 0.5 mg/mL (Trioxysalen). The patient then placed hands on UVA unit (Waldmann PUVA 180), body and face covered. Initially was given 0.10 Joule/cm2, dose was raised 0.05 Joule/cm2 at each treatment if tolerated by the patient. Max dose was 1.20 Joule/cm2. TL01 The patient placed hands on TL01 unit (Waldmann UV 181 BL), body and face cov- ered. Initially was given 0.1 Joule/cm2 Dermatology Reports 2012; volume 4:e3 Correspondence: Lisbeth Jensen, Department of Dermatology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark. E-mail: l.jensen@ouh.regionsyddanmark.dk Key words: PUVA soaks, hand eczema, quality of life, compositae allergy. Contributions: LJ, data collection, analyses, writ- ing drafts of article; AS, supervisor of qualitative part of study, revising article; KEA, supervisor of quantitative part of study, revising article. Conflict of interest: the authors have no conflict of interest. Aknowledgement: expenses covered by Depart- ment of Dermatology, Odense University Hospital, Denmark. Received for publication: 14 November 2011. Accepted for publication: 14 November 2011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0). ©Copyright L. Jensen et al., 2012 Licensee PAGEPress, Italy Dermatology Reports 2012; 4:e3 doi:10.4081/dr.2012.e3 No n- co mm er cia l u se on ly [Dermatology Reports 2012; 4:e3] [page 9] (eczema) - 0.2 Joule/cm2 (psoriasis), dose was raised 0.10 Joule/cm2 (eczema) - 0.20 Joule/cm2 (psoriasis) at each treatment if tol- erated by the patient. Max dose was 2.90 Joule/cm2. The observation period after a treatment course was 24 weeks, or until the patient was discharged. The treatment effect was evaluat- ed at the end of a treatment course by clinical evaluation of the severity of the hand dermato- sis in relation to the severity prior to treat- ment. Good effect was defined as healing of the dermatosis (effect 4) or at least 75% improvement (effect 3). Inadequate treatment effect was defined as clinical improvement less than 75%. The effect was evaluated again at the end of the observation period (24 weeks) or before if the patient had a relapse. Some patients had more than one diagnosis and were included once with the most promi- nent diagnosis. Semi structured interviews were done with a subgroup of 6 patients with multiple contact allergies (3 or more positive patch tests) and Compositae allergy. The informants were 49-67 years of age (mean age 56.5 years), and they had hand eczema for 12-42 years (mean number of years 38.5). An interview guide was developed for this investigation with questions about daily life events in relation to the contact allergies and hand eczema e.g. handling work, daily activi- ties, leisure time, and patients’ perspectives on these matters, and patients’ experiences and views on relationship with family, col- leagues, friends, and other people.14 Patients’ signed informed consents before the interviews, which were conducted in a neu- tral office in the ward or in patients’ home according to their preference. Patients’ were offered compensation for transport expenses in due course. The interviews were tape-recorded (26-50 min, mean number of min 40), tran- scribed word-for-word and then analysed and interpreted according to Steinar Kvale’s con- cepts.14 At the time of transcription each patient was given a fictive name. Interviews were rewritten into a shorter exact language easier to read with respect to meaning and the patients’ ways of expressing themselves. The text of each interview was then categorised in topics and subtopics and reorganized according to this. The patients’ statements were translat- ed from Danish into English by the author. Interpretation was done by reporting patients’ statements, rewriting them as the author understood them, and then compare them with the chosen theory by Heggdal.15 Patients go through four stages from the first symptoms and until they have accepted their chronic disease: uncertainty, loss, learning, and living with the disease. Results A total of 107 patients received 138 treat- ment courses of PUVA soaks or TL01 treat- ment, and 94 (81%) had ≥10 treatments in one course and a total of 121 courses. Figures 1 and 2 show that in 45/121 (37%) courses of PUVA soaks or TL01 the treatment was given with a good result, and in 76/121 (63%) the effect was inadequate. Side effects In 10 courses of PUVA soaks 8 patients experienced erythema and/or a burning sen- sation and 5 complained of pruritus and/or pain. In 2 courses of TL01 the patients had erythema and pruritus. In all cases the dura- tion of side effects was short. Patients having less than 10 treatments in one course In 18 courses 16 patients had less than 10 treatments. In 9 courses treatment was discontinued because of side effects/exacerbation, and in 9 courses treatment was discontinued because of no effect or because the patient decided to stop. Five patients had vesicular hand eczema, 4 patients had PPP, 4 had hyperkeratotic hand eczema, 2 had Compositae allergy and 1 had psoriasis. In 3 cases patients tolerated phototherapy in earlier courses, which meant they were not excluded from the study. Discussion Local phototherapy is often chosen as a sup- plement to patients’ treatment with topical steroids, and to make it possible for patients to stop using steroids for a period in order to min- imize possible side effects, for instance atro- phy of the skin. Local phototherapy can also be used as a supplement to or instead of systemic therapies if the patient does not tolerate or wish to use systemic therapies. Patients suffering from psoriasis and hyper- keratotic eczema had the best effect of PUVA soaks and TL01 (Figure 3). The effect was good for psoriasis in half of the treatment courses concerning PUVA soaks, and in one third of the courses with TL01. The effect of PUVA soaks are in accordance with results published by O’Kane and coworkers16 and Schempp and coworkers.17 Among patients with PPP and a total of 21 courses of PUVA soaks the effect was of ques- tionable value as it only lasted in more than 3 Article Table 1. Patient distribution regarding sex, age, number of treatments in one course, single, and cumulative doses of UVA for each diag- nosis. (J=Joule/cm2) Psoriasis Hyperkeratotic Pustulosis Vesicular Compositae Allergic eczema palmoplantaris eczema dermatitis contact dermatitis Sex Women 5 10 16 9 18 7 Men 8 15 5 5 2 2 Age Range 29-82 34-74 39-76 29-57 46-79 33-69 Median 57 52 59 46.5 54.5 51 Number of treatments Range 13-35 10-33 14-33 10-46 10-37 10-33 Median 21 23 22 22 15 20 Max single UVA dose Range 0.65-1.20 J 0.35-1.20 J 0.65-1.20 J 0.40-1.20 J 0.35-1.20 J 0.45-1.10 J Median 1.05 J 1.10 J 0.90 J 0.83 J 0.65 J 0.85 J Cumulative UVA dose Range 4.85-23.70J 2.35-26.40J 5.95-19.85J 2.07-39.20J 2.70-28.48J 3.85-13.45J Median 13.45 J 13.70 J 12.30 J 10.45 J 5.53 J 10.76 J No n- co mm er cia l u se on ly [page 10] [Dermatology Reports 2012; 4:e3] months in 4 patients. The effect could there- fore be spontaneous remission. Layton et al.18 conducted a placebo-controlled study, in which PUVA soaks (8-MOP emulsion) or placebo were used in 18 patients and there was no con- vincing effect of active treatment. Concerning vesicular eczema, one study reported that PUVA soaks (8-MOP solution) had good effect in 9/12 patients.19 The Behrens et al. study might be influenced by the exclusion cri- teria, as patients treated with systemic medica- tion within the last 8 weeks and topical medica- tion within the last 4 weeks were excluded, implying that patients included might have less severe hand eczema. In this study 5/14 (36%) of the patients obtained good effect. When evaluating the effect of PUVA soaks in patients with Compositae dermatitis, it is nec- essary to take into consideration that one patient accounted for 4 courses of good effect (effect 4) and the treatment was combined with systemic steroid which might amplify the effect. TL01 also worked well in the patient but the effect did not last. If this patient was left out, only one patient had good effect of the treatment, meaning 1/15 (7%). In 14 courses (93%) the treatment was given with inade- quate effect (effect 2, 1, 0). In 3/9 (33%) patients with allergic contact dermatitis PUVA soaks were given with good effect. The effect lasts for the observation period in 2 patients. No direct relationship was found between effect and number of treatments given. The treatment effect often began after 10-12 treat- ments, and patients who do not experience effect after 1 month seldom do so later,13 it seems reasonable to discontinue the treat- ment after 15 treatments if the patients have no effect. This corresponds to the Scottish treatment protocol from Photonet in which treatment is recommended discontinued if the patient does not experience more progress for 4 treatments in a row.20 In patients, who had more courses of PUVA soaks and TL01 pho- totherapy, the pattern of effect might differ from course to course. Several factors might influence this e.g. the fluctuation of disease severity, the time of year and environmental exposures at work and at home. A weakness in the study is the retrospective nature of data collection based on patient records with sometimes inadequate informa- tion. Some patients were treated with systemic treatments e.g. Methotrexate or Neotigason before, during or after phototherapy. Most of the patients were treated with topical steroids (group 3 or 4), and all patients used moisturiz- ers. The present results cannot be compared with the outcome of other studies due to char- acteristics of the selected patients material and possible differences in treatment proto- cols. However, the data are valuable as an audit for our department. Reservations must also be taken due to the low number of patients included. It was not possible to compare the effect of PUVA soaks and TL01 as only few patients received TL01. And as only few patients in the study had TL01 it was not possible to comment on the effect of the treatment to the included diagnoses. To be able to judge the effect of the treat- ment it is recommended to document patients’ symptoms at the 1st treatment and after 4 weeks. If the patients have no effect the treat- ment can be discontinued. If the patients have little effect treatment continues and the patients’ symptoms and thereby effect are judged every 2 weeks. When no further progress is observed the treatment is discon- tinued. Uncertainty and escaping the sick body The informants did not understand why they got hand eczema. The hand eczema had great impact on them and their self esteem. At first they ignored the eczema, it got worse, and eventually they had to deal with it. One saw a doctor after 2 years. I thought: It will disappear. It did, but then it got worse and worse... I have no idea what started it. (woman, 67 years old) Reduced life, sorrow and sadness Realizing having the eczema the informants felt depressed and tired. They needed to retreat to acquire peace and time to cope with the sit- uation. The following topics were found to be of sig- nificance: Affected state of mind, lack of ener- gy, retreat from other people, and the impor- tance of close relatives. Afffected state of mind Especially as the last allergy was Compositae, I almost ran from here crying. I dreaded this most. No, it is definitely not funny. (woman, 50 years old) The garden was important to some inform- ants. Working in the garden, being surrounded by plants and flowers, staying in the garden with friends and family, and participating in outdoor activities gave them quality of life. The worst of my diseases is the eczema. It influences my quality of life the most. I feel I am no good. I can do nothing. (woman, 67 years old) The informants felt sad and restricted by the hand eczema, and they felt less worthy as human beings. They were troubled by symp- toms like severe itching, pain and bleeding. Lack of energy I am happy when it is not there. Honestly, I get much more energy. (woman, 59 years old) When I get home from work there is no ener- gy left to do anything, because it takes up so much room. It hurts, and I am finally at home and can relax a little. At such times not much is being done. (woman, 56 years old) At times with severe hand eczema the informants only managed to carry out the most important duties. With those at work, the job was their priority, and with those at home like- wise only the most important jobs were done. Article Figure 1. Good effect (effect 4, 3) and inadequate effect (effect 2, 1, 0) of PUVA soaks, TL01, and both treatment modalities together. Number of treatment courses stated. No n- co mm er cia l u se on ly [Dermatology Reports 2012; 4:e3] [page 11] Retreat from other people I did not have any social contacts, and I didn’t want to be with my girlfriend either look- ing like this. (man, 49 years old) The informant retreated from colleagues, friends, and girlfriend because he could not stand his symptoms and the way he looked. He also retreated to avoid further confrontation with the situation and thereby protected him- self from any more pain. If we were going to a party and I had to say hello to many people, I kept my gloves on, and that was hard on me to begin with. I wondered if people thought I was contagious. But in the end I realized that I had to think of myself, otherwise I could go nowhere. (woman, 57 years old) Keeping up social activities took considera- tion and coming to terms with the situation before the informants could do so without strain e.g. using gloves and clothes also in warm weather. When the informants have come fur- ther in the process of living with hand eczema, they retreated from other people to protect themselves and because other people retreated from them. E.g. staying indoors or staying at home, explaining to people when they switched to another queue or ignoring them. The significance of close relatives Bent (husband) does not do housework, but he can peel onions for me and shape hamburg- ers. (woman, 56 years old) I have a good family and a very good husband, he has been there for me the whole time. He is worth his weight in gold. He helps at home. He often says: Leave that. (woman, 67 years old) The informants indicated how their close relatives helped to do practical housework, work in the garden, and offered support. Two informants described good support and help by relatives. With the other informants my impression was that they had to ask for help, which could be difficult. Bodily learning and strengthened hope The informants were eager to learn, but they also found it difficult to gather information on which plants and food were Compositae. Every time of success was a victory because they then knew more about how to prevent the eczema. They learnt to take care of their hands by using moisturizers and glove protection. They also learnt to be aware of limits in rela- tion to skin tolerance e.g. in relation to house- work, the use of gloves and staying outside. The informants were vulnerable in respect to the way they were met by people e.g. inform- ants who could see no pattern in their way of living, flares, and recovery gave up on it, their feeling of not being taken serious by health professionals accentuated this. It is a science to find out, which plants are Compositae, you cannot look them up in a book, you can, but you will only find a few. (woman, 50 years old) I get happy every time I find something that is no good for me. (woman, 67 years old) I wrote a note, and when I could do no more... I continued the next day...I knew if I did too much, my hands would hurt. (woman, 57 years old) Lately, especially after having phototherapy (TL01), it (the eczema) has changed, the itching has become different. (woman, 57 years old) Almost all the time I think of and remember that I have to take care of my hands. (woman, 57 years old) If only… but I can find no system. That is why I stopped coming here (dermatological clinic). I felt that I wasted my time, and I saw different doctors every time. (woman, 56 years old) Embedded bodily knowledge, living with hand eczema The informants indicated that they lived their lives with hand eczema and contact der- matitis in the way they wanted to in spite of limitations. They succeeded doing so by taking into account the knowledge and experience they had acquired and by being constantly alert. Limitations were of more or less nui- sance according to the informants’ individual interests. In cases of flares they knew what to do, they were able to begin treatment or to ask for help e.g. in the department of dermatology. They were worried about the long-term effect of sys- temic steroid, but at the same time they were aware that they could not do without it in cases of severe flares. I live with it in the way that I always try to be alert. I think of what I eat, what I do... If I don’t, I know I will start flaring and I don’t want that. (woman, 50 years old) I feel it starting, my hands get rough. Then I start using ... (a topical steroid), I sleep with gloves on and so forth. (woman, 67 years old) (PUVA soaks) is probably the best thing hap- pened to me. I feel completely different after treatments. (woman, 59 years old) I am a little worried that I get so many tablets (steroid). I am afraid they will damage me inside. I don’t like that. (woman, 59 years old) Conclusions The informants agreed that hand eczema fiercely intruded their lives as it affected them physically, psychologically, socially, and existen- tially and thereby had great influence on their daily living and quality of life. E.g. the inform- ants stated they had a lot of pain, they were very bothered by itching, they constantly had to be alert and perseverant in looking after and treat- ing their hands, they were noticed by other peo- ple, they looked different and were different to touch, and other people kept a distance. This corresponds with Diepgen stating that patients are not satisfied if health professionals only focus on treating visible signs of disease as the burden of disease is even more important.21 This is in accordance with Fowler who states that hand eczema is to be regarded as an impor- Article Figure 2. Effect of both treatment modalities divided on diagnoses. Good effect (effect 4, 3) and inadequate effect (effect 2, 1, 0). Number of treatment courses stated. No n- co mm er cia l u se on ly [page 12] [Dermatology Reports 2012; 4:e3] tant challenge in the health services.22 As reported by Cvetkovski other studies reveal that patients’ quality of life improve when patch tested and positive reactions are found,23 in this study the informants were relieved to know what they did not tolerate. With knowledge they were able to act in order to ease their eczema and regain control of their lives. Having a chronic disease includes the risk of recurrent relapses, which is trying for both patients and health professionals.22,24 In such situations the informants might bene- fit from the self esteem and confidence gained when the eczema was at ease, situations with feelings of having knowledge and control. In the study one informant chose to be dis- charged from the clinic because of the lack of feeling in control. Motivation and perseverance are important qualities having a chronic disease like hand eczema.25 The informants living best with their hand eczema described this very well. All the time they were alert, taking care, beginning treatment and taking extra precautions as soon as they sensed a flare was on its way. E.g. they all used a moisturizer of a high content of fat, and one used different moisturizers according to the eczema and the informant’s activities. All informants were worried about possible side effects to local or systemic steroid treatment. This is also referred to in Niemeier’s study.25 All the informants used gloves to varying degrees. They considered whether the gloves made them sweat, as this made their eczema worse, and they considered their activities. More studies emphasize the use of moisturizers and gloves as being the most important factors in the prevention of hand eczema, and also as important factors in the treatment of flares together with local steroids.26,24 Concerning phototherapy two informants were very satisfied with the effect of this, one had recurrent good effect of PUVA soaks, and one experienced that treatment with TL01 made the eczema change into being milder. Another factor which is emphasised concerning allergic contact hand dermatitis is the importance of avoiding the allergen.26,27 This may be extremely difficult with Compositae allergy as the plants in the family are widespread both as cultivated plants, weeds, and vegetables as well as the allergen being airborne.28 The informants did their best to avoid Compositae taking their own experi- ences into account. They wore clothes, stayed indoors, and converted their gardens, which restricted their interests, activities, and social lives. Having to beware of their diet bothered them the least, as it was of no importance to them avoiding cosmetics containing Compo- sitae. Concerning work one informant was able to keep the job, one was able to make arrange- ments to stay employed, one found a new job, and three had pension. This contradicts to a study mentioned by Diepgen in which 15% leave work because of hand eczema.21 It might have been of some importance that all the informants in this study had wet work, which could have made it more difficult for them to take necessary precautions. Recommendation To be able to help future patients in carrying and possibly ease their burden of living with chronic hand eczema and allergic contact der- matitis health professionals are suggested to support patients in finding joy and experienc- ing victory of finding out what they do not tol- erate and what works in their situation. This means helping them to find their individual limits and solutions according to limits and preferences. Our task as health professionals is to make our theoretical and experience based knowledge available to the patient, e.g. about hand eczema, allergy, treatment, and prevention. The information must be adapted to the patient’s capability at the time. The patient’s task is to transform the knowledge presented into practical knowledge in the patient’s current life situation. Health profes- sionals must continuously be ready to offer more knowledge or to challenge the patient to consider the situation. In order to optimize the learning situation it is proposed that the patient is connected with a team of doctors and nurses having the neces- sary knowledge, also as the patient might be coming back over some time. Health professionals are also suggested to visit patient’s home and work in order to gath- er more information and inspiration for the education of this and other patients.29 References 1. Coevorden AMV, Coenraads PJ, Svensson A, et al. Overview of studies of treatments for hand eczema - the EDEN hand eczema survey. Br J Dermatol 2004;151:446-51. 2. Hald M, Berg ND, Elberling J, Johansen JD. Medical consultations in relation to severity of hand eczema in the general population. Br J Dermatol 2008;158:773-7. 3. Sezer E, Erbil AH, Kurumlu Z, et al. Comparison of the efficacy of local narrow- band ultraviolet B (NB-UVB) phototherapy Article Figure 3. Good and inadequate effect of PUVA soaks and TL01 shown for each diagnosis. Number of treatment courses stated. No n- co mm er cia l u se on ly [Dermatology Reports 2012; 4:e3] [page 13] versus psoralen plus ultraviolet A (PUVA) paint for palmoplantar psoriasis. J Dermatol 2007;34:435-40. 4. Sezer E, Etikan I. Local narrowband UVB phototherapy vs. local PUVA in the treat- ment of chronic hand eczema. Photo-der- matol Photoimmunol Photomed 2007;23: 10-4. 5. Taylor CR, Baron ED. Hand and foot PUVA soaks: An audit of the Massachusetts General Hospital's experience from 1994 to 1998. Photodermatol Photoimmunol Photomed 1999;15:188-92. 6. Menné T, Veien N, Sommerlund M, Jet al. Operationelle retningslinier for udredning og behandling. Dansk Kontakt Dermatitis Gruppe 2009;1-39. 7. Lerbaek A, Kyvik KO, Ravn H, et al. Clinical characteristics and consequences of hand eczema - an 8-year follow-up study of a population-based twin cohort. Contact Dermatitis 2008;58:210-6. 8. Carlsen BC, Andersen KE, Menné T, Johansen JD. Sites of dermatitis in a patch test population: hand dermatitis is associ- ated with polysensitization. Br J Dermatol 2009;161:808-13. 9. Agner T, Andersen KE, Brandao FM, et al. Contact sensitisation in hand eczema patients - relation to subdiagnosis, severi- ty and quality of life: a multi-center study. Contact Dermatitis 2009;61:291-6. 10. Burke DA, Corey G, Storrs FJ. Psoralen Plus UVA Protocol for Compositae Photosensitivity. Am J Contact Dermatitis 1996;7;171-6. 11. Skoet R, Zachariae R, Agner T. Contact der- matitis and quality of life: a structured review of the literature. Br J Dermatol 2003;149:452-6. 12. Diepgen TL. Chronisches Handekzem. Epidemiologie und therapeutische Evi- denz. Hautarzt 2008;59:683-9. 13. Shephard SE, Schregenberger N, Dummer R, Panizzon RG. Comparison of 8-MOP Aqueous Bath and 8-MOP Ethanolic Lotion (Meladinine) in Local PUVA Therapy. Dermatology 1998;197:25-30. 14. Kvale S. Interview. En introduktion til det kvalitative forskningsinterview. Køben- havn: Hans Reitzels Forlag; 1997. 15. Heggdal K. Kroppskunnskaping. Pasienten som ekspert i helsefremmende prosesser. Oslo: Gyldendal Norsk Forlag AS; 2008. 16. O´Kane D, McLoone NM, Jenkinson H, et al. Efficacy of topical PUVA soaks for pal- moplantar dermatoses: an audit. Photo- dermatol Photoimmunol Photomed 2008; 24:279-84. 17. Schempp CM, Müller H, Czech W, et al. Treatment of chronic palmoplantar eczema with local bath-PUVA therapy. J Am Acad Dermatol 1997;36:733-7. 18. Layton AM, Sheehan-Dare R, Cunliffe WJ. A double-blind, placebo-controlled trial of topical PUVA in persistent palmoplantar pustulosis. Br J Dermatol 1991;124:581-4. 19. Behrens S, von Kobyletzki G, Gruss G, et al. PUVA-bath photochemotherapy (PUVA- soak therapy) of recalcitrant dermatoses of the palms and soles. Photodermatol Photoimmunol Photomed 1999;15:47-51. 20. NHS Scotland - Photonet (National Managed Clinical Network For Photo-ther- apy). Treatment Protocols. 2010. Available from: http://www.photonet.scot.nhs.uk/ Documents%20on%20Professionals%20Pa ge/Photonet%20Treatment%20Protocols% 202010%20.pdf 21. Diepgen T, Agner T, Aberer W, et al. Management of chronic hand eczema. Contact Dermatitis 2007;57:203-10. 22. Fowler J. Chronic Hand Eczema: a preva- lent and challenging skin condition. Cutis 2008;82Suppl4:3-8. 23. Cvetkovski RS, Zachariae R, Jensen H, et al. Quality of life and depression in a pop- ulation of occupational hand eczema patients. Contact Dermatitis 2006;54:106- 11. 24. Bikowski JB. Hand Eczema: Diagnosis and Management. Cutis 2008;82Suppl4:9-15. 25. Niemeier V, Nippesen M, Kupfer J, et al. Psychological factors associated with hand dermatoses: which subgroup needs addi- tional psychological care? Br J Dermatol 2002;146:1031-7. 26. Bourke J, Coulson I, English J. Guidelines for the management of contact dermatitis: an update. Br J Dermatol 2009;160:946-54. 27. Smith MC, Nedorost ST. Hand Dermatitis: nursing support in the plan of care. Dermatol Nurs 2008;20:121-5. 28. Gordon LA. Compositae dermatitis. Australas J Dermatol 1999;40:123-30. 29. van Gils RF, van der Valk PGM, Bruynzeel D, et al. Integrated, multidisciplinary care for hand eczema: design of a randomized controlled trial and cost-effectiveness study. BioMed Central Public Health 2009;9. Article No n- co mm er cia l u se on ly