Typical UVB Narrowband Cabinet

We’ve seen a few reports out of New Zealand with respect to the use of ultraviolet light. Here’s one I added to our blog in July: < click here > 

Recently (12 October) another article was posted about the use of UVB and kids. The study involed  116 children. Here’s the essence of the article.

Background:  Phototherapy is effective for many dermatoses in adults, but there is a paucity of data for its use in children. 

Objectives:  To review the efficacy and tolerability of narrowband UVB phototherapy in children at a tertiary centre in New Zealand, and determine if there were any factors that differentiated responders from non-responders. 

Methods:  A prospective analysis of children (<16 years old) who had undergone phototherapy over a 15-year period. 

Results:  116 children received phototherapy with a total of 144 courses. Mean age was 11.0 years with the majority being European and having skin phototype II. Atopic dermatitis was the most common indication for treatment followed by psoriasis, pityriasis lichenoides, nodular prurigo, morphea, vitiligo, urticaria pigmentosa and erythropoietic porphyria. Treatment was effective in the majority of children (72%). Most received only one course. For responders, the mean number of treatments was 32.4. The mean dose per treatment to achieve clearance was 886 mJ/cm2 and the mean maximum treatment dose per treatment was 1328 mJ/cm2. All children tolerated treatment well with 36% developing brief, minimally symptomatic, erythema. Only two children experienced exacerbations of their underlying dermatoses. 

Conclusions:  This study shows that phototherapy is an effective and well-tolerated treatment modality in children. 

UVB Narrowband products for home and clicical use can be found at www.homephototherapy.com

A question that comes up quite often is “Should I use Protopic?” or perhaps “Should I use Elidel?” and then the question continues “… while using UVB Narrow Band?”.

Generally speaking, any drug or cream should be avoided and not be applied immediately before or during UVB Narrow Band treatment. Elidel and Protopic and most other things you apply to your skin, change the skin’s sensitivity to UV light. Some drugs increase your sensitivity (Psoralens & others) while others reduce your skin’s sensitivity (sun blocks and the like). All of these should be avoided UNLESS SPECIFICALLY PRESCRIBED by your Dermatologist.

I do recommend that if Protopic, Elidel or other Corticosteroid has been prescribed that you use it following UV treatment or on the alternate days. Do not apply these creams before treatment UNLESS SPECIFICALLY PRESCRIBED by your Dermatologist. It is not safe to apply these creams before treatment as they can increase your skin’s sensitivity to UV light and increase the risk of severe erythema (sunburn).

Do no assume that you know more than your dermatologist!

Avoid sunlight, sun lamps, tanning beds, and phototherapy treatments with UVA or UVB light. If you must be outdoors, wear loose clothing over the skin areas treated with Protopic. Do not use sunscreen on treated skin unless your doctor has told you to.

• Read more: http://www.drugs.com/protopic.html
• Read more: http://www.drugs.com/elidel.html

Folks with Psoriasis and Eczema usually respond quickkly to treatment and begin to see results with in the first week or so and treatments then continue for a month or two with most people clearing within a few months.

Here’s a page at National Psoriasis Foundation on UVB Phototherapy
Excerpt from page “Several studies indicate that narrow-band UVB clears psoriasis faster and produces longer remissions than broad-band UVB. Narrow-band UVB may be effective with fewer treatments per week than broad-band UVB. Narrow-band UVB is also emerging as an alternative to PUVA, the light-sensitizing medication psoralen plus exposure to ultraviolet light A. Although not as effective as PUVA, narrow-band UVB is easier for people to undergo and may be safer over the long term. The use of narrow-band UVB may increase as doctors and patients learn more about its effectiveness and safety…” See http://www.psoriasis.org/treatment/psoriasis/phototherapy/uvb.php

With Eczema and Psoriasis, what do you do when clearing has happened?

1. Wait for a re-occurence and start treatments again or
2. Perform a weekly maintenance dose at perhaps 75% of the last treatment time.

In either case, check with your dermatologist or medical professional. As a reminder, please read our disclaimer.

They report, Compared with broadband UVB:

• Exposure times are shorter but of higher intensity.
• The course of treatment is shorter.
• It is more likely to clear the skin condition.
• Longer periods of remission occur before it reappears.

They also mention that “This range of UV radiation has proved to be the most beneficial component of natural sunlight for psoriasis. Narrowband UVB may also be used in the treatment of many other skin conditions including atopic eczema, vitiligo, pruritus, lichen planus, polymorphous light eruption, early cutaneous T-cell lymphoma and dermographism.”

The original can be found at http://dermnetnz.org/procedures/narrowband-uvb.html - Enjoy!

The new Dermalume 2X uses the National Biological Corp CPT or Controlled Prescription Timer to help the doctor and the patient work together for optimal treatment.

It’s interesting to see the sales of our Dermalight 80 drop slightly as our sales of the Dermalume ramp up.

The Dermalume 2X arrives ready for use in a handy briefcase type case allowing the user to easily pack it away between treatments and carry it with them while traveling.

The unit allows the user to treat only affected areas – and use comb to maintain consistent distance from skin or separate hairs for scalp psoriasis treatment.

The clever hinge allows multiple wand positions can be held where you want while the two lamps with the large output window allow for faster treatment. The DermaLume is shipped fully assembled with an optional comb attachment (includes) , goggles, and carrying case.

You can learn more about the Dermalume 2X at our website. Please visit http://www.homephototherapy.com/dermalume2X.htm for more information.

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.

One area of ongoing investigative research compares narrow-band ultraviolet B light (NB-UVB) with psoralen–ultraviolet A light (PUVA) treatment. While PUVA, usually with oral 8-methoxypsoralen, seems to result in more rapid clearance of psoriasis plaques with fewer adverse events, more research with larger numbers of patients needs to be done.

General Principles

AAD’s phototherapy guidelines recommend that all patients undergo a complete history and physical before undertaking phototherapy for psoriasis. Among those who should not be treated with phototherapy are patients with lupus or xeroderma pigmentosum.

Careful screening is required before undertaking phototherapy in patients taking photosensitizing medications; patients having a photosensitivity disorder, a history of melanoma, atypical nevi, multiple risk factors for melanoma, or multiple non–melanoma skin cancers; or patients who are immunosuppressed as the result of organ transplant, according to Dr. Menter, chair of the AAD Psoriasis Work Group, and his associates.

UVB Phototherapy

UV radiation ranging from 254 nm to 313 nm producing suberythemogenic exposure leads to significant improvement of psoriasis. NB-UVB, which involves use of a bulb that emits light between 311 and 313 nm, has been proved superior to the broadband (BB)-UVB at both inducing and maintaining remission. NB-UVB seems to have immunosuppressive effects that are useful in the treatment of psoriasis.

The guidelines include tables outlining previously published, “well-accepted” dosing regimens for both BB- and NB-UVB (J. Am. Acad. Dermatol. 2009 [doi 10.1016/j.jaad.2009.08.026]).

Burning is as common with NB-UVB as with BB-UVB. Data from murine studies suggest that NB-UVB is two to three times as carcinogenic as BB-UVB. However, given that its higher efficacy results in less exposure, NB-UVB may not pose more significant long-term risk of carcinogenesis.

While pregnant women may be at increased risk for melasma from NB-UVB, it is not contraindicated in this population. It should be used as the first-line therapy in pregnant women with plaque and guttate psoriasis, wrote Dr. Menter. Judicious use of NB-UVB should be considered as a second-line therapy in children who do not benefit from topical therapy.

UVB Combination Therapy

There are no randomized studies on the benefit of applying a topical agent in preparation for UVB phototherapy, despite the fact that doing so is a mainstay of phototherapy. The data are mixed on the efficacy of combining the vitamin D analogue calcipotriol with phototherapy. The greatest benefit is seen when it is used in combination with NB-UVB. However, it should be applied after phototherapy to avoid degradation from exposure to UV radiation, according to the guidelines.

The use of methotrexate in combination with phototherapy seems to speed clearance. However, psoriasis may flare once methotrexate is discontinued. Use of retinoids in combination with UVB speeds the therapeutic response, lowering the total exposure to UV radiation, although clinicians have been unwilling to avail themselves of this therapeutic option, according to the authors.

Dr. Menter served on the advisory board of and was a consultant, investigator, and speaker for numerous pharmaceutical companies as have the other 12 members of the work group.

This article can be found in the December 2009 issue of SKin and Allergy News. It was written by Sally Koch Kubetin

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

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.

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>

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.