Can PUVA (Psoralen and Ultraviolet A) therapy cause testicle damage and high FSH (Follicle-Stimulating Hormone) levels?

PUVA Therapy and Testicular Damage with Elevated FSH

Yes, PUVA therapy can cause testicular damage, and genital shielding during treatment is mandatory to prevent this complication, though the primary concern documented in guidelines is squamous cell carcinoma of the male genitalia rather than direct gonadal toxicity with FSH elevation.

Primary Risk: Genital Squamous Cell Carcinoma

The most well-established testicular/genital risk from PUVA is malignancy, not hormonal dysfunction:

• The risk of squamous cell carcinoma of the male genitalia is particularly elevated with PUVA therapy 1
• This elevated genital cancer risk is the primary reason for the recommendation to shield the genital area during all PUVA treatments 1
• High cumulative PUVA exposure (≥200 treatments or ≥2000 J/cm²) increases squamous cell carcinoma risk 14-fold compared to low-dose exposure 1

Direct Gonadal Toxicity and FSH Elevation

The available guidelines do NOT specifically document PUVA causing direct testicular damage with FSH elevation. However, important context exists:

What Guidelines Address:

• Oral psoralen is contraindicated in pregnancy 1
• PUVA is mutagenic and carcinogenic 1
• No specific mention of testicular atrophy, oligospermia, or FSH elevation as PUVA side effects in major dermatology guidelines 1

Critical Distinction from Other Therapies:

• Methotrexate (alternative psoriasis treatment) is explicitly documented to decrease sperm count 1
• Radiation therapy and chemotherapy for testicular cancer cause well-documented testicular damage with elevated FSH and reduced sperm counts 2, 3, 4
• The scattered radiation (0.2-1.3 Gy) reaching testicles during cancer radiotherapy causes azoospermia and FSH elevation 4

Clinical Implications and Recommendations

Mandatory Protective Measures:

• Shield the male genitalia during every PUVA treatment session 1
• This protects against both malignancy risk and any potential direct gonadal effects from UVA exposure
• Use opaque covering or protective garments for complete genital protection 1

If FSH is Already Elevated in a PUVA Patient:

Consider alternative causes first:

• Prior chemotherapy or radiation exposure (causes persistent FSH elevation and testicular damage) 2, 3, 4
• Concurrent methotrexate use (known to decrease sperm count) 1
• Primary testicular pathology unrelated to PUVA
• Inadequate genital shielding during previous PUVA sessions (theoretical UVA-induced damage)

Treatment Modifications:

• If testicular concerns exist, consider switching to narrowband UVB therapy instead of PUVA 1
• NB-UVB avoids psoralen-related systemic effects while being only slightly less effective than PUVA 1
• For patients with fertility concerns, biologics or other systemic agents may be preferable to PUVA 1

Common Pitfalls to Avoid

• Do not assume PUVA is the cause of elevated FSH without excluding other etiologies (chemotherapy, radiation, primary hypogonadism are better-documented causes) 2, 3, 4
• Never perform PUVA without genital shielding in male patients - this is non-negotiable 1
• Do not combine PUVA with cyclosporine in patients with high PUVA exposure (dramatically increases skin cancer risk) 1
• Avoid PUVA in patients with prior high-dose radiation or chemotherapy exposure (additive carcinogenic risk) 1

Monitoring Recommendations

For male patients receiving PUVA:

• Annual genital skin examination for squamous cell carcinoma (especially with >200 treatments) 1
• If fertility is a concern, obtain baseline sperm analysis and FSH before initiating PUVA
• Consider alternative therapies (NB-UVB, biologics) for men actively pursuing fertility 1