Home UVB phototherapy for Psoriasis
Alex Anstey – professor – Royal Gwent Hospital, Newport NP20 2UB – alex.anstey@gwent.wales.nhs.uk - Research, doi:10.1136/bmj.b1542
Is as safe and effective as outpatient treatment, but provision is poor. Psoriasis is a common chronic inflammatory skin condition that causes substantial disability in affected people and their families. In the linked randomised controlled trial (doi:10.1136/bmj.b1542), Koek and colleagues assess whether home ultraviolet B (UVB) phototherapy is as safe and effective for psoriasis as conventional UVB phototherapy given in the outpatient department.
UVB has been used to treat psoriasis for more than 75 years, initially in combination with crude coal tar, and later as monotherapy. UVB has been the phototherapy of choice for psoriasis since it was found to be less carcinogenic than PUVA (psoralen plus ultraviolet A phototherapy), and since the development in the late 1980s of a highly efficacious UVB lamp, termed “narrow band UVB.”
Patients taking a course of UVB treatment usually attend their local dermatology unit three times each week for eight to 10 weeks. In many cases this leads to complete or almost complete clearance of disease. The duration of clearance is variable but often persists for months. In spite of this impressive efficacy and relatively few side effects, few patients with psoriasis receive UVB treatment. In the NHS most patients with psoriasis are managed in primary care, where phototherapy is seldom available. Dermatology units in the United Kingdom and other developed countries typically cover large geographical areas with a single phototherapy unit in a central “hub and spoke” model. When patients’ travelling time, loss of earnings, and travel costs are considered, only those living locally to a phototherapy unit can be expected to attend up to 30 times in a 10 week period.
Home phototherapy for psoriasis was introduced in Sweden in the late 1970s to treat patients living far from their local phototherapy unit. Subsequent open uncontrolled studies in rural United States, the Netherlands, and Scotland confirmed the feasibility of this model and were generally positive about outcomes. Despite this, few dermatologists have embraced home phototherapy; when asked why not, they cite inferior efficacy and higher risks, despite the absence of evidence to support these assumptions. Thus, home phototherapy remains unavailable to most patients with psoriasis.
To date, research on home phototherapy has been limited to open studies assessing its practicalities. No trials have compared home phototherapy with conventional hospital based phototherapy. Koek and colleagues’ trial is a pragmatic study that compares home UVB with outpatient UVB as part of normal clinical practice. In addition to assessing the safety and efficacy of the two treatments, they also examined quality of life, burden of treatment, and patient satisfaction. The study found that the treatments had similar efficacy, cumulative doses of UVB, and rates of short term side effects. However, the burden of treatment was significantly lower for patients treated at home, and these patients were more positive about the treatment. Improvements in quality of life were similar for both groups. Basic health economic data from Scotland comparing the two different models of care previously concluded that home phototherapy was cost effective. More detailed health economic analysis is now needed to clarify the cost implications of hospital based UVB phototherapy and home UVB phototherapy.
What are the implications of this study’s results for clinical practice? The study highlights an important gap in the provision of treatment for patients with psoriasis. With new potent, but costly, biological treatments now widely available for moderate to severe psoriasis, it is timely to reassess conventional treatments such as UVB. It would be inappropriate for patients to receive these new and expensive treatments when the infrastructure to deliver well established cheaper treatments, such as UVB, is lacking.
Dermatologists should reflect on the shortcomings of current phototherapy services, where many patients are excluded because they live too far from their local unit. The case for home provision of UVB phototherapy for psoriasis is most persuasive in sparsely populated areas. Experience in Germany, the US, the Netherlands, and Scotland confirms that it would be feasible and practical to implement home based UVB phototherapy.
How can home based phototherapy become a reality? Now that safety and efficacy concerns have been tackled, an economic assessment of different UVB service models is needed. This should include the costs of the equipment, costs of teaching patients how to use the equipment, and costs for a clinical governance system within which home phototherapy can operate. Meanwhile, healthcare commissioners should work with local dermatologists to improve access to UVB phototherapy services. A pragmatic interim solution to create more accessible and equitable UVB services might be to deliver phototherapy from “spokes” as well as, or instead of, the “hub.”
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Koek MBG, Buskens E, van Weelden H, Steegmans PHA, Bruijnzeel-Koomen CAFM, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009;338:b1542.
Goeckerman WH. Treatment of psoriasis. Arch Dermatol Syphilol 1931;24:446-50.
Adrian RM, Parrish JA, Momtaz TK, Karlin MJ. Outpatient phototherapy for psoriasis. Arch Dermatol 1981;117:623-6.
Ibbotson SH, Bilsland D, Cox NH, Dawe RS, Diffey B, Edwards C, et al. An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group workshop report. Br J Dermatol 2004;151:283-97.
Larkö O. Treatment of psoriasis with a new UVB lamp. Acta Derm Venereol (Stockh) 1989;69:357-9.
Larkö O, Swanbeck G. Home solarium treatment of psoriasis. Br J Dermatol 1979;101:13-6.
Jordan WP Jr, Clarke AM, Hale RK. Long-term modified Goekerman regimen for psoriasis using an ultraviolet B light source in the home. J Am Acad Dermatol 1981;4:584-91.
Van Vlotten WA. Home treatment of psoriasis using ultraviolet-B irradiation. Ned Tijdschr Geneeskd 1993;137:2525-6.
Cameron H, Yule S, Moseley H, Dawe RS, Ferguson J. Taking treatment to the patient: development of a home TL-01 ultraviolet B phototherapy service. Br J Dermatol 2002;147:957-65.
Koek MBG, Buskens E, Bruijnzeel-Koomen CAFM, Sigurdsson V. Home ultraviolet B phototherapy for psoriasis: discrepancy between literature, guidelines, general opinions and actual use. Results of a literature review, a web search, and a questionnaire among dermatologists. Br J Dermatol 2006;154:701-11.
Cite this as: BMJ 2009;338:b607
Having problem with our skin can give us depression, yes it is due to the anxiety that we feel when we see other people staring at you and looking in your dry loose aging skin! Many people specially women who are experiencing this kind of scenario, but don’t worry there are many machine and procedures that can help us to stay away from this stage of our lives. Thanks to technology, for providing us high quality gadgets to improve our appearance and to gain confidence.