The World of UV Phototherapy

Posts Tagged ‘Psoriasis’

One of the realities we live with at Amjo is that many derms look at UV Phototherapy as a last resort. The typical derm would prefer to prescribe biologics and other ointments and salves, many of which expose the patient to higher risks than UVB Narrowband Phototherapy. The article below is one of the few that I’ve come across recommending UV Phototherapy.

The American Academy of Dermatology’s latest guidelines on the management of psoriasis and psoriatic arthritis focus on phototherapy.

Despite therapeutic advances in recent years, phototherapy remains an important treatment option for patients with psoriasis, according to Dr. Alan Menter, chairman of the division of dermatology at Baylor University Medical Center in Dallas, and his associates.

Read the rest of this entry »

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.

Read the rest of this entry »

The breakthrough came after 1988 when narrow-band UVB (NB-UVB) phototherapy was introduced for the treatment of psoriasis…

Narrow band UVB phototherapy in dermatology

AUTHORS: Sunil Dogra, Amrinder Jit Kanwar
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India

Full Article < Click Here >

The first report of the use of ‘phototherapy’ in the treatment of skin disorders dates from 1400 BC from India when patients with vitiligo were given certain plant extracts (whose active ingredients included psoralens) and then exposed to the sun. The real interest in the use of ultraviolet (UV) irradiation in the treatment of various skin diseases started in the 19th century when Niels Finsen received the Nobel Prize (1903) for his therapeutic results with UV irradiation in lupus vulgaris, the only dermatologist ever to be awarded one. This marked the start of modern phototherapy. It was used in thermal stations for the treatment of tuberculosis, in the treatment of leg ulcers in wartime, and various other skin diseases. It was a very long journey from the use of plant extracts and sun exposure to treat vitiligo to the use of oral psoralens and total body UVA-irradiation cabins (PUVA) to treat various skin diseases. In a landmark development, in 1974 Parrish et al reported the useful role of high intensity UVA tubes in combination with oral psoralens in the treatment of psoriasis leading to what is now known as PUVA therapy.

The history of UVB phototherapy is not as old as the history of photochemotherapy. Wiskemann introduced irradiation cabin with broad band UVB tubes in 1978 for the treatment of psoriasis and uremic pruritus. However, broad band UVB phototherapy was less efficient for treating psoriasis than PUVA and so never achieved popularity. The breakthrough came after 1988 when narrow-band UVB (NB-UVB) phototherapy was introduced for the treatment of psoriasis by van Weelden et al and Green et al.

It’s great to have an independent source ratify what we’ve known for years. UV Phototherapy at home is safe, well tolerated and here in the USA, very cost effective for the patient and the insurance company that sometimes is paying the bill.

Since the publishing of the article on May 7th by the British Medical Journal on the effectiveness of UVB Treatment in the home, the Internet has been buzzing with articles written by a host of reviewers on the subject. Most are simply referring to the original article but many are commenting. Most if not all of the postings I’ve seen on various blogs and publications show strong support for the use of UVB Narrowband Therapy in the home.

This of course is like music to my ears. Many of you know that I run a business offering UV Phototherapy Products for use in the home. See www.HomePhotoTherapy.com. So of course I’m a little biased.

The actual heading of the article is “Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study)”

The finding by the researchers who followed 196 patients was “Ultraviolet B phototherapy administered at home is equally safe and equally effective, both clinically and for quality of life, as ultraviolet B phototherapy administered in an outpatient setting. Furthermore, ultraviolet B phototherapy at home resulted in a lower burden of treatment and led to greater patients’ satisfaction. “

This statement flies in the face of many dermatologists that say that they believe that treatment at home is the wrong approach because they believe that patients will not be compliant at home. It’s interesting to note that many of the derms who make such ridiculous statements have phototherapy systems in their offices or clinic and they draw some of their income for the sale of time in their own phototherapy systems. I guess it shows that even doctors like to make a dollar.

Treatment at home is ultimately much less expensive to the patient and the insurance company than in-clinic treatment. Typical home equipment can range from $600.00 to $7000.00 with most folks spending perhaps $2500.00 on a home system. In clinic rates can vary from a low of $25.00 to a high of $90.00 PER TREATMENT. I we take an average of let’s say $40.00/treatment with three treatments a week then that’s $120.00/week and in 20 weeks ($2400.00), the typical home system would be paid for. That does not include the costs of parking, car mileage, time of work.

Visit www.HomePhotoTherapy.com to see some home systems. Remember most folks over a lifetime require treatment sometimes several times a year, perhaps for a lifetime.

The absolute best way to have UV Treatment is in the home.

<Link to original article>

SOURCE: Kristina Fiore, Staff Writer, MedPage Today
Published: May 08, 2009
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

TITLE: Home phototherapy is comparable to hospital-based ultraviolet B treatment for psoriasis patients, researchers have found.

In a randomized controlled trial, home phototherapy was as safe and effective as hospital-based treatment, Mayke Koek, M.D., of the University Medical Center Utrecht in the Netherlands, and colleagues reported online in BMJ.

“We regard home ultraviolet B phototherapy to be a worthy alternative to standard outpatient ultraviolet B phototherapy for patients with psoriasis,” the researchers concluded.

They explained that many patients who could benefit from phototherapy don’t get it because of time constraints: treatment typically involves going to the hospital three times a week for eight to 10 weeks.

Also, some dermatologists believe that home phototherapy is inferior to hospital treatment and carries more risks, such as inaccurate dosimetry, phototoxicity, and unsupervised continuation of irradiation. The researchers said there is little evidence for this.

So the present study looked at 196 psoriasis patients from 14 hospital dermatology departments in the Netherlands who received either home- or hospital-based phototherapy.

Home therapy patients used a TL-01 home phototherapy unit, while those who came to the hospital for treatment received standard, narrowband ultraviolet B phototherapy.

The researchers found that home phototherapy was as safe and effective as outpatient phototherapy, both clinically and in terms of quality of life.

A total of 82% of patients treated at home reached a treatment effect as measured by the self-administered psoriasis area and severity index (SAPASI), compared with 79% of those treated in an outpatient setting.

Likewise, 70% reached treatment effect as measured by the clinically assessed psoriasis area and severity index (PASI), compared with 73% of outpatients.

The treatment effects were significant across all groups (P<0.001).

As for safety concerns, the researchers found that patients treated themselves at home more frequently than they would have been treated at the hospital. But the cumulative dose they received by the end of treatment was only slightly higher than hospital-treated patients.

They found that regardless of treatment, 87% of patients had at least one occurrence of mild erythema, while 58% reported burning sensations, 39% had severe erythema, and 6% had blistering. No differences were observed between groups.

“Our results refute the widespread fear of more acute safety risks with ultraviolet B phototherapy used at home,” the researchers said.

They also found that the burden of undergoing phototherapy was significantly lower for patients treated at home (P<0.001).

Quality of life increased equally, regardless of treatment, but those treated at home were more likely to rate their experience with the therapy as “excellent” (42% versus 23%, P=0.001).

The researchers concluded that phototherapy administered at home is “equally safe and equally effective, both clinically and for quality of life, as ultraviolet B phototherapy administered in an outpatient setting.”

In an accompanying editorial, Alex Anstey, M.D., of Royal Gwent Hospital, called the study “pragmatic” and said an economic assessment of different phototherapy service models is now 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,” Dr. Anstey said.

He added that 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.”

Sources Cited:
Primary source: British Medical Journal
Source reference:
Koek MBG, et al “Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicenter randomized controlled non-inferiority trial (PLUTO study)” BMJ 2009; DOI: 10.1136/bmj.b1542.

Additional source: British Medical Journal
Source reference:
Anstey A “Home UVB phototherapy for psoriasis” BMJ 2009; DOI: 10.1136/bmj.b1542.

Published 7 May 2009, doi:10.1136/bmj.b1542
Cite this as: BMJ 2009;338:b1542

Research

Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study)

Mayke B G Koek, research fellow¹, Erik Buskens, professor of medical technology assessment^2,3, Huib van Weelden, investigator photodermatology¹, Paul H A Steegmans, dermatologist⁴, Carla A F M Bruijnzeel-Koomen, professor of dermatology/allergology¹, Vigfús Sigurdsson, dermatologist¹

¹ Department of Dermatology/Allergology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands, ² Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands, ³ Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands, ⁴ Department of Dermatology, St Antonius Hospital, Nieuwegein, Netherlands

Correspondence to: M B G Koek author@koek.com

Objective To determine whether ultraviolet B phototherapy at home is equally safe and equally effective as ultraviolet B phototherapy in an outpatient setting for patients with psoriasis.

Design Pragmatic multicentre single blind randomised clinical trial (PLUTO study).

Setting Dermatology departments of 14 hospitals in the Netherlands.

Participants 196 patients with psoriasis who were clinically eligible for narrowband (TL-01) ultraviolet B phototherapy. The first 105 consecutive patients were also followed for one year after therapy.

Intervention Ultraviolet B phototherapy at home using a TL-01 home phototherapy unit compared with standard narrowband ultraviolet B phototherapy in an outpatient setting. Both therapies were done in a setting reflecting routine daily practice in the Netherlands.

Main outcome measures The main outcome measure was effectiveness as measured by the proportion of patients with a 50% or more reduction of the baseline psoriasis area and severity index (PASI) or self administered psoriasis area and severity index (SAPASI), called the PASI 50 and SAPASI 50 (relevant treatment effect). Another outcome of effectiveness was the percentage reduction in median scores on the PASI as well as SAPASI. Also the proportions of patients reaching the PASI 75 and SAPASI 75 (successful treatment effect), and the PASI 90 and SAPASI 90 (almost complete clearance) were calculated. Other secondary outcomes were quality of life (SF-36, psoriasis disability index), burden of treatment (questionnaire), patients’ preferences and satisfaction (questionnaire), and dosimetry and short term side effects (diary).

Results 82% of the patients treated at home compared with 79% of the patients treated in an outpatient setting reached the SAPASI 50 (difference 2.8%, 95% confidence interval -8.6% to 14.2%), and 70% compared with 73% reached the PASI 50 (-2.3%, -15.7% to 11.1%). For patients treated at home the median SAPASI score decreased 82% (from 6.7 to 1.2) and the median PASI score decreased 74% (from 8.4 to 2.2), compared with 79% (from 7.0 to 1.4) and 70% (from 7.0 to 2.1) for patients treated in an outpatient setting. Treatment effect as defined by the mean decline in PASI and SAPASI scores was significant (P<0.001) and similar across groups (P>0.3). Total cumulative doses of ultraviolet B light were similar (51.5 v 46.1 J/cm², difference 5.4, 95% confidence interval -5.2 to 16.0), and the occurrence of short term side effects did not differ. The burden of undergoing ultraviolet B phototherapy was significantly lower for patients treated at home (differences 1.23 to 3.01, all P 0.001). Quality of life increased equally regardless of treatment, but patients treated at home more often rated their experience with the therapy as “excellent” (42%, 38/90) compared with patients treated in the outpatient department (23%, 20/88; P=0.001).

Conclusion Ultraviolet B phototherapy administered at home is equally safe and equally effective, both clinically and for quality of life, as ultraviolet B phototherapy administered in an outpatient setting. Furthermore, ultraviolet B phototherapy at home resulted in a lower burden of treatment and led to greater patients’ satisfaction.

^{<Original Article - Click Here>}

Published 7 May 2009, doi:10.1136/bmj.b607
Cite this as: BMJ 2009;338:b607

Editorials

Home UVB phototherapy for psoriasis

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.¹

UVB has been used to treat psoriasis for more than 75 years, initially in combination with crude coal tar,² and later as monotherapy.³ UVB has been the phototherapy of choice for psoriasis since it was found to be less carcinogenic than PUVA (psoralen plus ultraviolet A phototherapy),⁴ and since the development in the late 1980s of a highly efficacious UVB lamp, termed “narrow band UVB.”⁵

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 . . . [Full text of this article]

Alex Anstey, professor

¹ Department of Dermatology, Royal Gwent Hospital, Newport NP20 2UB

alex.anstey@gwent.wales.nhs.uk

Authors: Pediatric Dermatology. 13(5):406-409, September/October 1996.
Tay, Yong-Kwang M.D. *; Morelli, Joseph G. M.D. ; Weston, William L. M.D.+

Abstract:  Twenty children age 14 months to 12 years with photoresponsive dermatoses were treated with ultraviolet B (UVB) phototherapy over four years. Ten children had psoriasis, five had pityriasis lichenoides, and five had atopic dermatitis. All received short courses (average 34 treatments) of phototherapy with either no maintenance or short maintenance. Treatment was effective and well tolerated in most patients, and no serious side effects were seen. Patients with psoriasis and pityriasis lichenoides cleared completely. No patient with atopic dermatitis cleared completely, but all were moderately improved, with reduction of the extent of eczema and decreased pruritus. It appears that UVB phototherapy is a valuable and safe therapeutic option for selected children who do not respond to other treatments.

Authors and Disclosures:
K. M. Cordoro, MD, Department of Dermatology,
University of California, San Francisco, CA, USA

Phototherapy is an excellent, safe, and appropriate treatment for carefully selected patients with refractory plaque, guttate and pustular disease, diffuse (>15%-20% body surface area) involvement, or focal debilitating palmoplantar psoriasis. To avoid burns and other light-associated complications, it is essential to utilize a phototherapy unit with experienced and well-trained personnel who are comfortable working with children. Three main types of therapeutic light options exist: broadband UVB (BB-UVB, 280-320nm), NB-UVB (311-313nm) and UVA (320-400nm).

BB-UVB encompasses the most biologically active radiation in sunlight and guttate psoriasis responds best, but plaque psoriasis in children tends to be thinner and will respond to higher doses and a longer duration of treatment. One of the greatest advances in phototherapy for psoriasis is the use of NB-UVB, which, at therapeutic doses, is lesserythemogenic than other wavelengths in the UVB range.[16]

Centered on 311-313nm, NB-UVB is safe and effective for a number of photoresponsive dermatoses in children, including psoriasis.[17-19] Short-term side-effects of UVBphototherapy are usually mild and consist of xerosis, erythema, pruritus, and photoactivation of herpesvirus. Potential long-term effects include premature photoagingand cutaneous carcinogenesis.[20]

Photochemotherapy (psoralen plus ultraviolet A, [PUVA]) is based on the interaction between UVA radiation and psoralen, a photosensitizing chemical. In children less than12 years, oral PUVA is rarely used and if so, is done with extreme caution and should be restricted to psoriasis and phototherapy centers staffed by well trained, experiencedphysicians and nurses.

Many authors consider oral psoralen relatively contraindicated in children less than age 12 and prefer topical PUVA because of the many short- and longterm toxicities associated with psoralen ingestion (e.g., nausea, vomiting, headache, hepatotoxicity, generalizedphotosensitization requiring 24 hours of photoprotection, ocular toxicity, acute risk of burning, and long-term risk of skin cancer).[21] In children, NB-UVB is more convenient and may be less carcinogenic. Given the downsides of using psoralens in children and adults, NB-UVB is now considered first-line phototherapy.[22]

1. Kopp T, Karlhofer F, Szepfalusi Z, et al. Successful use of acitretin in conjunction with narrowband ultraviolet B phototherapy in a child with severe pustular psoriasis, von Zumbusch type. Br J Dermatol 151(4):912-6 (2004 Oct).
2. Lee CS, Koo J. A review of acitretin, a systemic retinoid for the treatment of psoriasis. Expert Opin Pharmacother 6(10):1725-34 (2005 Aug).
3. Lacour M, Mehta-Nikhar B, Atherton DJ, et al. An appraisal of acitretin therapy in children with inherited disorders of keratinization. Br J Dermatol 134(6):1023-9 (1996 Jun).
4. Brecher AR, Orlow SJ. Oral retinoid therapy for dermatologic conditions in children and adolescents. J Am Acad Dermatol 49(2):171-82 (2003 Aug).
5. Katugampola RP, Finlay AY. Oral retinoid therapy for disorders of keratinization: single-centre retrospective 25 years´ experience on 23 patients. Br J Dermatol 154(2):267-76 (2006 Feb).
6. Halverstam CP, Zeichner J, Lebwohl M. Lack of significant skeletal changes after long-term, low-dose retinoid therapy: case report and review of the literature. J Cutan Med Surg 10(6):291-9 (2006 Nov-Dec).
7. Paller AS. Dermatologic uses of methotrexate in children: indications and guidelines. Pediatr Dermatol 2(3):238-43 (1985 Mar).
8. Callen JP, Kulp-Shorten CL, Wolverton SE. Methotrexate. In: Wolverton SE, editor. Comprehensive dermatologic drug therapy. 2nd ed. Philadelphia: Saunders Elsevier; p163-81 (2007).
9. Swords S, Lauer SJ, Nopper AJ. Principles of treatment in pediatric dermatology: systemic treatment. In: Schachner LA, Hansen RC, editors. Pediatric dermatology. 3rd ed. Philadelphia: Mosby (Elsevier); p133-43 (2003).
10. Gisondi P, Fantuzzi F, Malerba M, et al. Folic acid in general medicine and dermatology. J Dermatolog Treat 18(3):138-46 (2007).
11. Lebwohl M, Ali S. Treatment of psoriasis. Part 2. Systemic therapies. J Am Acad Dermatol 45(5):649-61 (2001 Nov).
12. Pereira TM, Vieira AP, Fernandes JC, et al. Cyclosporin A treatment in severe childhood psoriasis. J Eur Acad Dermatol Venereol 20(6):651-6 (2006 Jul).
13. Koo J. Systemic sequential therapy of psoriasis: a new paradigm for improved therapeutic results. J Am Acad Dermatol 41(3 Pt 2):S25-8 (1999 Sep).
14. Ellis CN. Safety issues with cyclosporine. Int J Dermatol 36 Suppl 1:7-10 (1997 Dec).
15. Cordoro KM, Feldman SR. TNF-alpha inhibitors in dermatology. Skin Therapy Lett 12(7):4-6 (2007 Sep).
16. Kist JM, Van Voorhees AS. Narrowband ultraviolet B therapy for psoriasis and other skin disorders. Adv Dermatol 21:235-50 (2005).
17. al-Fouzan AS, Nanda A. UVB phototherapy in childhood psoriasis. Pediatr Dermatol 12(1):66 (1995 Mar).
18. Jain VK, Aggarwal K, Jain K, et al. Narrow-band UV-B phototherapy in childhood psoriasis. Int J Dermatol 46(3):320-2 (2007 Mar).
19. Tay YK, Morelli JG, Weston WL. Experience with UVB phototherapy in children. Pediatr Dermatol 13(5):406-9 (1996 Sep-Oct).
20. Pasic A, Ceovic R, Lipozencic J, et al. Phototherapy in pediatric patients. Pediatr Dermatol 20(1):71-7 (2003 Jan-Feb).
21. Wolff K. Side-effects of psoralen photochemotherapy (PUVA). Br J Dermatol 122 Suppl 36:117-25 (1990 Jun).
22. MacDonald A, Burden AD. Psoriasis: advances in pathophysiology and management. Postgrad Med J 83(985):690-7 (2007 Nov).
23. Owen CM, Chalmers RJ, O´Sullivan T, et al. A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis. Br J Dermatol 145(6):886-90 (2001 Dec).
24. Wilson JK, Al-Suwaidan SN, Krowchuk D, et al. Treatment of psoriasis in children: is there a role for antibiotic therapy and tonsillectomy? Pediatr Dermatol 20(1):11-5 (2003 Jan-Feb).
25. Lebwohl M. Combination, rotational and sequential therapy. In: Weinstein G, Gottlieb A, editors. Therapy of moderate to severe psoriasis. 2nd ed. New York: Marcel Dekker; p179-95 (2003).

Sunshine can also beat back the chronic autoimmune disorder of the skin. But explaining light’s therapeutic effects has been difficult. “We know it works, but we want to know how,” says Michelle Lowes, an assistant professor of clinical investigation in the Laboratory for Investigative Dermatology at Rockefeller University. “Does it target the pathways that we think are important in the disease?”

A new clinical trial under way at the Center for Clinical and Translational Science in The Rockefeller University Hospital will literally shine light on the disease in hopes of finding out. Researchers, including Lowes and Clinical Research Nurse Practitioner Patricia Gilleaudeau, have recruited the first of what will be 20 patients who will visit the hospital three times a week for up to four months to receive narrowband ultraviolet light B (UVB) treatment. Patients will give skin and blood samples as the treatment takes its course, giving the scientists the possibility to study what is happening at the molecular level as the skin gets better.

UVB therapy is known to kill off T cells, which are partly to blame for the inflammation caused by the disease. For years, Lowes has been systematically accounting for the cell types and proteins involved in the disease. She is specifically interested in whether UVB targets a pathway involving two immune system proteins called cytokines, which she believes may disrupt certain types of T cells and another specialized group of immune-directing dendritic cells. “If we can define the mechanism of action we may potentially have new therapeutic targets for psoriasis and other diseases,” says Lowes, the recipient of a 2008 Doris Duke Charitable Foundation Clinical Scientist Development Award, which is supporting the study.

Doctors often recommend UVB therapy if standard ointment treatments fail and if patients would rather avoid a systemic immunosuppressive drug regimen that has been developed more recently. Patients receive the treatment, brief blasts of UVB, standing inside an upright cabinet whose inside is lined with fluorescent tube lights. The duration of the light exposure increases over the course of the treatment.

In addition to providing free treatment to the study participants, Gilleaudeau consults with the patients and their families and directs them to resources for getting the equipment they need to administer the treatment at home. “We try to help them continue with treatment after they leave whenever we can,” says Gilleaudeau, who will staff a table for The Rockefeller University Hospital May 3 at the National Psoriasis Walk for Awareness in the New York Botanical Garden. “We want to help.”

Lowes hopes to have some preliminary results in about a year. “We are excited about studying this commonly used therapy for psoriasis with modern methods, and hope that this will lead to a better understanding of this complicated and common skin disease,” she says.

http://www.rockefeller.edu/