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Journal of the American Academy of Dermatology
Volume 66, n° 4
pages 553-562 (avril 2012)
Doi : 10.1016/j.jaad.2011.04.004
accepted : 11 April 2011
Original Articles

The risk of squamous cell and basal cell cancer associated with psoralen and ultraviolet A therapy: A 30-year prospective study

Robert S. Stern, MD

PUVA Follow-Up Study

Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 

Correspondence to: Robert S. Stern, MD, Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, GZ-522, Boston, MA 02215.

By 1977, psoralen and ultraviolet A (PUVA) was established as a highly effective therapy for psoriasis. Because of concerns about potential long-term adverse effects, particularly cancer, the PUVA Follow-Up Study was established to assess long-term risk and benefits of PUVA.


We sought to determine the association of certain squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) risk with exposure to PUVA.


For nearly 30 years, this prospective cohort study of 1380 patients with psoriasis first treated with PUVA in 1975 to 1976 documented exposures and incident events including biopsy-proven skin cancers.


From 1975 to 2005, 351 of 1380 (25%) cohort patients developed 2973 biopsy-proven SCC and 330 (24%) developed 1729 BCCs. After adjusting for age, gender, and significant confounders, the risk of developing one or more SCC in a year was strongly associated with total number of PUVA treatments (350-450 vs <50 treatments, incidence rate ratio [IRR] = 6.01, 95% confidence interval [CI] = 4.41-8.20). When all tumors are included this risk is significantly higher (IRR = 20.92, 95% CI = 14.08-31.08). Corresponding risks for BCC were much lower (person counts IRR = 3.09, 95% CI = 2.36-4.06; tumor counts IRR = 2.12, 95% CI = 1.47-3.05).


This was an observational prospective study of a cohort with severe psoriasis. An unknown factor associated with higher dose exposure to PUVA in our cohort that was not included in our analysis could account for the observed associations.


Exposure to more than 350 PUVA treatments greatly increases the risk of SCC. Exposure to fewer than 150 PUVA treatments has, at most, modest effects on SCC risk. Even high-dose exposure to PUVA does not greatly increase BCC risk. The risks of SCC in long-term PUVA-treated patients should be considered in determining the risk of this therapy relative to other treatments for severe psoriasis.

The full text of this article is available in PDF format.

Key words : basal cell cancer, binomial regression, cohort study, Cox proportional hazard, prospective, psoralen plus ultraviolet A, psoriasis, risk factors, squamous cell cancer

Abbreviations used : BCC, CI, IRR, NMSC, PUVA, SCC, UV

 Supported in part by National Institutes of Health Contract No. NO1-AR-0-2246.
 Conflicts of interest: None declared.
 Reprints not available from the authors.

© 2011  American Academy of Dermatology, Inc.@@#104156@@