An Update on At-Home UVB Phototherapy
At-home options increase accessibility to phototherapy, which is effective and generally safe for psoriasis management.
By Joseph Bikowski, MD
Use of light for the treatment of skin diseases dates back at least to the time of the ancient Egyptians, although controlled scientific investigation of phototherapy for psoriasis did not occur until the late 1800s. With developments in UV phototherapy over the 20th century, light-based treatment for psoriasis has become firmly established and has been thoroughly reviewed in the AAD’s “Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis.”1 Within this recent publication, the expert psoriasis work group affirms the potential benefits of athome UVB phototherapy, citing recent studies that have confirmed its efficacy.2,3
The market for at-home UVB units has increased in recent years, and systems provide a variety of features to enhance patient convenience, therapeutic efficacy, and safety. A recent article in Practical Dermatology4 (August 2010 edition, available online at PracticalDermatology.com) provided an overview of at-home phototherapy for psoriasis. The introduction of a novel at-home UVB unit (Levia, Lerner Medical Devices, Inc.), now allows targeted treatment of smaller anatomic areas and the scalp. Ahead is a brief review of at-home phototherapy and a look at the latest addition to the field.
Phototherapy is established as a safe and effective treatment for moderate to severe psoriasis.5 Types of phototherapy for psoriasis include psoralen plus ultraviolet A (PUVA), broadband UVB (280- 315nm), and narrowband UVB (311nm). Targeted light-based treatment with the 308nm excimer laser has also been employed with success in the management of moderate to severe psoriasis.6 The excimer laser system has largely been advocated for the treatment of smaller body surface areas.7
The use of UVA phototherapy in conjunction with psoralen, known as PUVA, is quite effective and recently has been shown to offer similar efficacy to biologic therapy for psoriasis.8 In a small study comparing PUVA to UVA plus placebo, PUVA was found to be significantly more effective than UVA alone; 63 percent of PUVA-treated subjects achieved PASI 75, compared with no subjects in the UVA plus placebo group.9 UVA-based phototherapy is associated with increased risk of cutaneous malignancies. A largescale follow-up study of patients treated with PUVA identified an increased risk of melanoma occurring 15 years after the first treatment and increasing as the total number of treatments exceeded 250.10 Coupled with well-known acute side effects, including nausea, this risk of malignancy has contributed to an overall reduction in the use of PUVA, although it is recognized as a valid treatment option for mild to moderate psoriasis.
Broadband and narrowband UVB are considered less likely to cause cutaneous malignancies. A retrospective analysis has shown no increase in cancer incidence among psoriasis patients treated with either form of UVB.11 Of the two forms, NB-UVB is more effective than BB-UVB12,13 and is therefore more commonly used. The Goeckerman regimen, which includes the use of coal tar in addition to UVB, offers very good efficacy,14 but it is messy and time-consuming.
UVB phototherapy is typically provided in an outpatient clinic, requiring patients to travel to the clinic two to three times a week for treatment. Some clinics offer expanded hours in efforts to accommodate patients and increase the convenience of therapy. Still, the onus on patients is thought to diminish compliance with in-office phototherapy. Additionally, many insurers require a patient co-pay each time the individual presents for phototherapy in the clinic. Given multiple visits per week, the costs to the patient can escalate quickly.
Developed largely in response to the need for greater patient convenience and potentially lower overall costs, home UVB phototherapy units have been available for roughly three decades. Although home phototherapy is well tolerated and cost-effective, a significant proportion of dermatologists do not prescribe it,15 perhaps due to perceived risks and lack of familiarity regarding procurement of a system. A primary concern among clinicians is that patients will apply excessive doses of UVB and subsequently develop burns. However, most if not all home systems currently on the market have safety features that limit the amount of energy that can be distributed and are designed to prevent system misuse.
Many home phototherapy systems are full-body or large flat-panel systems. New to the market is a system designed for “personal targeted phototherapy” (PTP) that is ideal for small treatment areas and the scalp. Levia delivers 300-320nm UVB energy from a compact six-pound console that measures six inches wide, 8 inches high, and 11.5 inches deep. The system features an easy-to-use touch-screen interface and offers two handpieces: the LiteSpot and the LiteBrush. The standard handpiece treats an area of 3cm2, while the brush, specially designed for treatment of scalp psoriasis, uses fiberoptics to bypass hair and deliver UVB energy to the scalp.
The physician fully controls the prescription for light administration. The information provided by the prescriber and input into the system determines the maximum total number of treatments, the dose of each treatment, and any limitations on treatment. Once the patient has completed the prescribed course, they may be required to present to the clinic for follow-up before additional treatments are prescribed.
The system monitors patient response to therapy and uses the information to manage treatment. For example, before activating the light source, the system requires that patients input information about the response to prior treatment, including degree of erythema and any signs and symptoms of burning. Each patient receives a six-digit prescription code or PIN, and a 10-digit therapeutic code that are used to activate the system and dispense the physician-directed therapy. Data are stored in the system, allowing the prescriber to determine whether the patient has been compliant with treatments.
Like other manufacturers of at-home UVB devices (Table 2), Lerner Medical Devices, Inc. provides support to physicians and patients for the ordering of at-home phototherapy. There is assistance available for obtaining insurance approval and a sample letter for medical necessity. System training is available to patients acquiring a system. The Levia system is also approved for treatment of vitiligo and atopic dermatitis. The system has a five-year lamp life.
Home UVB phototherapy can be used alone or in combination with other therapies for the management of psoriasis. Traditional home systems are ideal for the management of larger body surface areas, while the novel at-home system offers an option for the treatment of smaller surface areas and the scalp. Light-based therapy may be particularly suited to patients who have failed to respond or have had sub-optimal response to other treatments or who wish to avoid systemic medications or long-term topical corticosteroid use.
Although home-based phototherapy systems are safe, patients require regular follow-ups to ascertain the level of response and set the course for continuing therapy. Follow-up appointments at three-month intervals have been advocated for all patients undergoing at-home phototherapy. It may be appropriate to see a patient two to four weeks after the initiation of at-home therapy to monitor response and address any concerns.
Rethinking Home Phototherapy
As the treatment of psoriasis has evolved in recent years, clinicians have faced a growing number of treatment options for the disease. Among the available treatments, phototherapy has a long history of use and a good deal of clinical evidence. While there are relevant safety concerns associated with the use of UVA and UVB phototherapy, when provided under appropriate protocols, light therapy is quite safe.
In addition to safety concerns, lack of access has also limited the use of phototherapy. A number of practices simply do not offer phototherapy in the clinic. Among practices that do, patient access can be limited by logistics (inability to present multiple times per week for treatment) or costs.
At-home UVB units offer a reasonable alternative for many patients. Larger systems have been available for some time, with a track record of safety and efficacy. Now targeted treatment of small surface areas is also possible. Clinicians should consider at-home phototherapy among the treatment options for their patients with moderate to severe psoriasis or those with less extensive but recalcitrant plaques.
Dr. Bikowski does not have any relevant relationships to disclose.
Joseph Bikowski, MD is Clinical Assistant Professor of Dermatology at Ohio State University in Columbus, OH and Director of Bikowski Skin Care Center in Sewickley, PA.
- Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Lebwohl M, Lim HW, Van Voorhees AS, Beutner KR, Bhushan R. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. 2010 Jan;62(1):114-35.
- Koek MB, Buskens E, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ. 2009 May 7;338:b1542.
- Koek MB, Sigurdsson V, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Buskens E. Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomised controlled trial (PLUTO study). BMJ. 2010 Apr 20;340:c1490.
- Bhutani T, Liao W. A Practical Approach to Home UVB Phototherapy for the Treatment of Generalized Psoriasis. 2010; 7(8):31-35.
- Gattu S, Pugashetti R, Koo J. The art and practice of UVB phototherapy and laser for the treatment of moderate-to-severe psoriasis. In: Koo J, Lee CS, Lebwohl MG, Weinstein GD, Gottlieb A, editors. Moderate to Severe Psoriasis. Third Edition ed. New York, NY: Informa Healthcare; 2009. p. 75-114.
- Han L, Somani AK, Huang Q, Fang X, Jin Y, Xiang LH, Zheng ZZ. Evaluation of 308-nm monochromatic excimer light in the treatment of psoriasis vulgaris and palmoplantar psoriasis. Photodermatol Photoimmunol Photomed. 2008 Oct;24(5):231-6.
- PD ARTICLE
- Inzinger M, Heschl B, Weger W, Hofer A, Legat FJ, Gruber-Wackernagel A, Tilz H, Salmhofer W, Quehenberger F, Wolf P. Efficacy of PUVA therapy versus biologics in moderate to severe chronic plaque psoriasis: retrospective data analysis of a patient registry. Br J Dermatol. 2011 May 12., e-pub
- Sivanesan SP, Gattu S, Hong J, Chavez-Frazier A, Bandow GD, Malick F, Kricorian G, Koo J. Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks. J Am Acad Dermatol. 2009 Nov;61(5):793-8.
- Stern RS, Nichols KT, Väkevä LH. Malignant melanoma in patients treated for psoriasis with methoxsalen (psoralen) and ultraviolet A radiation (PUVA). The PUVA Follow-Up Study. N Engl J Med. 1997 Apr 10;336(15):1041-5.
- Weischer M, Blum A, Eberhard F, Röcken M, Berneburg M. No evidence for increased skin cancer risk in psoriasis patients treated with broadband or narrowband UVB phototherapy: a first retrospective study. Acta Derm Venereol. 2004;84(5):370-4.
- Lapolla W, Yentzer BA, Bagel J, Halvorson CR, Feldman SR. A review of phototherapy protocols for psoriasis treatment. J Am Acad Dermatol. 2011 May;64(5):936-49.
- Coven TR, Burack LH, Gilleaudeau R, Keogh M, Ozawa M, Krueger JG. Narrowband UV-B produces superior clinical and histopathological resolution of moderate-to-severe psoriasis in patients compared with broadband UV-B. Arch Dermatol. 1997 Dec;133(12):1514-22.
- Chern E, Yau D, Ho JC, Wu WM, Wang CY, Chang HW, Cheng YW. Positive Effect of Modified Goeckerman Regimen on Quality of Life and Psychosocial Distress in Moderate and Severe Psoriasis. Acta Derm Venereol. 2011 May
- Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatology Online Journal. 2010;16(2):1
Chapter 27 -- Breast Cancer Genomics, Section VI, Pathology and Biological Markers of Invasive Breast Cancer
Spellman, Paul T. ; Heiser, Laura ; Gray, Joe W.
Breast cancer is predominantly a disease of the genome with cancers arising and progressing through accumulation of aberrations that alter the genome - by changing DNA sequence, copy number, and structure in ways that that contribute to diverse aspects of cancer pathophysiology. Classic examples of genomic events that contribute to breast cancer pathophysiology include inherited mutations in BRCA1, BRCA2, TP53, and CHK2 that contribute to the initiation of breast cancer, amplification of ERBB2 (formerly HER2) and mutations of elements of the PI3-kinase pathway that activate aspects of epidermal growth factor receptor (EGFR) signaling and deletion of CDKN2A/B that contributes tomore » cell cycle deregulation and genome instability. It is now apparent that accumulation of these aberrations is a time-dependent process that accelerates with age. Although American women living to an age of 85 have a 1 in 8 chance of developing breast cancer, the incidence of cancer in women younger than 30 years is uncommon. This is consistent with a multistep cancer progression model whereby mutation and selection drive the tumor's development, analogous to traditional Darwinian evolution. In the case of cancer, the driving events are changes in sequence, copy number, and structure of DNA and alterations in chromatin structure or other epigenetic marks. Our understanding of the genetic, genomic, and epigenomic events that influence the development and progression of breast cancer is increasing at a remarkable rate through application of powerful analysis tools that enable genome-wide analysis of DNA sequence and structure, copy number, allelic loss, and epigenomic modification. Application of these techniques to elucidation of the nature and timing of these events is enriching our understanding of mechanisms that increase breast cancer susceptibility, enable tumor initiation and progression to metastatic disease, and determine therapeutic response or resistance. These studies also reveal the molecular differences between cancer and normal that may be exploited to therapeutic benefit or that provide targets for molecular assays that may enable early cancer detection, and predict individual disease progression or response to treatment. This chapter reviews current and future directions in genome analysis and summarizes studies that provide insights into breast cancer pathophysiology or that suggest strategies to improve breast cancer management.« less