I n recent years, photomedicine, the therapeutic use of UV radiation and visible light, has become a critical weapon in the war against skin disorders. With bold, new approaches and innovative phototherapies, photomedicine now offers the promise of effectively treating the most intractable of dermatoses. Researchers and clinicians have developed a wide range of phototherapeutic techniques to treat a variety of conditions, including psoriasis, vitiligo and cutaneous T-cell lymphoma. Bath-PUVA and combinations with other topical and systemic treatment modalities can be used to either reduce side effects or enhance efficacy. Narrowband UVB and UVA-1 radiation along with selected spectra visible light are proving to be effective and potentially lower-risk alternative treatments for a wide range of dermatoses. Narrowband UVB Phototherapy Broadband UVB phototherapy (270 nm to 350 nm) is a very effective therapeutic strategy for psoriasis and other skin conditions, with a safety profile backed up by long-term follow-up studies. However, narrowband (311 nm to 313 nm) may be a better option. “Studies show that the maximum clearing occurs at 311 nm. The advantage of that is that you get rid of all the high-energy short wavelengths,” said Thomas Schwarz, M.D., Vice Chairman, Department of Dermatology, University of Muenster, Germany. “Since this is the much safer therapy, the narrowband in the long term will replace broadband in this application. I’m not aware of any study showing that the narrowband is inferior to the UVB.” According to Dr. Schwarz, another advantage to narrowband UVB is that higher energy levels can be used, resulting in greater clearing without increasing the risks and side effects. “Studies show that the minimal erythema dose (MED) for broadband is around 76 mJ/cm2, but with the 311 nm it was around 410 mJ/cm2, which is a big difference,” said Dr. Schwarz. “In addition, studies showed that while doses at 70% MED did clear faster, doses at 30% MED were equally effective and required only more sessions.” The lower MED would result in a lower total cumulative dose at the end of therapy. In his practice, Dr. Schwarz usually prescribes therapy for patients five times per week, but acknowledged that studies show that treatment three times per week may provide the best combination of timely clearing and low cumulative dosing. For narrowband treatments, Dr. Schwarz uses the Phillips TL01 bulb that has its maximum output near 311 nm. Erythema occurs within 12 hours after UVB treatment, so the next day a physician can easily see whether the dose given the day before was the appropriate one or not. Dosage can be adjusted as therapy progresses, increasing or decreasing the dose based on the level of erythema. Dr Schwarz has one caveat when using narrowband to treat a patient. “You must be careful when moving a patient from a narrowband to a broadband unit. A patient exposed to the same energy levels on the broadband unit as he or she received on the narrowband unit would suffer extreme erythema.” Conditions that Respond Best A number of skin conditions can be treated with broadband and narrowband UVB. According to Dr. Schwarz, UVB can be used for atopic dermatitis, and narrowband UVB may be the more effective phototherapy. In addition, studies show that vitiligo responds to low-dose phototherapy, especially in children. But while some studies showed repigmentation of up to 100% in some patients, most patients had unacceptable repigmentation levels. Mycosis fungoides (cutaneous T-cell lymphoma) responds well to either broadband or narrowband UVB; however, Dr. Schwarz said that PUVA therapy is as effective and may result in longer lasting remissions. Combining Therapies A number of therapies can be combined with UVB to improve the effectiveness of the therapy or reduce side effects. Studies show that if you precondition the skin with vitamin D and administer systemic retinoids for a few weeks prior to starting the UVB that you can reduce the cumulative dose. “The application of topical vitamin D after UVB treatment can improve the results of each treatment and lower the cumulative doses,” said Dr. Schwarz. “Studies have also shown that you can also combine topical retinoids such as tazarotene (Tazorac) and lower the total cumulative UV doses.” Tazarotene is photo-stable, but Dr Schwarz warned it may irritate some patients. When using tazarotene, start conservatively at the beginning of treatment and lower the dose. PUVA Photochemotherapy According to Henry W. Lim, M.D., Chairman and C. S. Livingood Chair, Department of Dermatology at Henry Ford Hospital in Detroit, a number of skin disorders, including psoriasis, vitiligo and cutaneous T-cell lymphoma, respond successfully to PUVA photochemotherapy. This therapy involves administering a psoralen followed by PUVA. Currently, the only psoralen available in the United States is 8-methoxypsoralen (8-MOP). The typical treatment cycle for 8-MOP is two or three times per week. When administered, 8-MOP is absorbed quite well with a peak photosensitization occurring between 1 to 3 hours after ingestion. “The standard regimen is to administer the 8-MOP an hour before starting treatment,” explained Dr. Lim. “Usually we start with 0.5 mg/kg to 0.6 mg/kg. 8-MOP is available in 10-mg capsules.” The peak spectral output of light used is 350 nm. For starting dose, Dr. Lim uses the skin type to guide therapy, and he suggests the following: Patients with skin type I. Start with 1 J/cm or 1.5 J/cm2. Patients with skin type III. Use 3 J/cm2 to 3.5 J/cm2. Patients with skin type VI. Use 6 J/cm2 to 6.5 J/cm2. “In terms of increment, use 0.5 J/cm2 to 1.5 J/cm2, depending on the skin type,” Dr. Lim advised. Dr. Lim warned that the photosensitivity and the serum level are both affected if the patient eats just prior to taking the medication, and he recommends low-fat meals. “The best results can be obtained by ensuring that patients maintain a consistent interval between eating and taking the psoralen and eat the same type of food each time before taking the psoralen,” said Dr. Lim. “Patients should be warned about possible photosensitivity for the day of the administration and must wear UV-protective lenses when they go outside or when near windows.” According to Dr. Lim, patients under the age of 10 should not be treated, and extreme care should be taken when treating patients between 10 and 18 years of age. Patients with a history of melanoma, lupus erythematosis, xeroderma pigmentosum, dysplastic nevi, non-melanoma skin cancer or photosensitivity, or taking medications that make them photosensitive should not be treated; nor should pregnant or nursing women. Patients undergoing treatment with cyclosporine should not have PUVA treatments. In addition, exposure to ionizing radiation, arsenical injection, tacrolimus (Protopic), pimecrolimus (Elidel) and methotrexate potentially increase PUVA photocarcinogenicity. Not only has Dr. Lim’s own experience with the therapy convinced him of its effectiveness, he also cited a number of other studies with good results. “In a U.S. study involving more than 1,100 patients, 89% cleared, typically after 25 treatments over 12 weeks,” said Dr. Lim. “A similar European study of 3,000 patients produced similar results in somewhat less time, though some of the patients had received retinoids.” PUVA can be combined with other treatments, including topical corticosteroids, anthralin (Psoriatic Cream) and calcipotriol ointment (Dovonex). At least one study suggested that a combination of PUVA plus vitamin D derivative topical or PUVA plus tazarotene topical may be more effective than PUVA alone. Systemic or topical retinoids with PUVA have been used with very good success. Multiple studies show that PUVA is a very good treatment for mycosis fungoides (cutaneous T-cell lymphoma), primarily because you can achieve remission for a consistently longer period of time than with most other treatments. PUVA has been shown to be up to 85% effective in more than 70% of patients with vitiligo of the head, neck, upper arms, legs and trunk. Patients may get complete re-pigmentation, and this area may be stable for long periods. Distal hands and feet and the lips are poorly responsive. Genital areas should be shielded. According to Dr. Lim, the most common side effects of PUVA are nausea and, less commonly, vomiting, which can be easily managed. “Several methods can control nausea,” said Dr. Lim. “Having the patient eat prior to taking the pills or having them take the pills individually over about a half an hour are simple approaches.” More persistent nausea can be treated with anti-nausea medication approximately 30 minutes prior to ingesting psoralen. Dizziness and headaches have been infrequently reported. Dr. Lim noted several side effects associated with PUVA treatments. Erythema can occur depending upon the dose and the patient’s sensitivity; it peaks between 48 and 72 hours after treatment. Skin fragility resulting in the development of friction blisters can develop. Melanonychia, especially in darker- skinned individuals, can also occur, though it resolves if you stop the PUVA. Pruritus is another acute side effect. The so-called PUVA itch is localized primarily to the mid-back, and is often severe, persistent and resistant to therapy. Photoaging can result from long-term treatment, with a majority of patients experiencing significant photoaging in exposed areas. Skin Cancer Risks According to Dr. Lim, there are significant skin cancer risks for PUVA chemotherapy. Studies show a significant increase in the risk of malignant melanoma and squamous cell carcinoma for high-dose patients (greater than 200 treatments or 2,000 J/cm2). Male genitalia appear to be especially susceptible. However, a large Swedish study involving nearly 5,000 men and women with a follow-up period of more than 15 years found no increase in melanoma. Some of the Swedish patients were treated with trimethylpsoralen (not available in the United States). PUVA Variants (Bath-PUVA, Combination Treatments) PUVA is a recognized and effective therapy for a wide range of skin disorders. Today, researchers are investigating ways of improving the therapy by combining PUVA with other treatments. “The aim of combining PUVA with other treatments is to either reduce side effects, such as prolonged photosensitivity, erythema and carcinogenesis, or to increase the efficacy of the treatment,” explained Herbert Hönigsmann, M.D., Chairman of the Division of Special and Environmental Dermatology at the University of Vienna Medical School in Austria. “Typical combined PUVA therapies include PUVA with topical therapy, PUVA with systemic therapy and topical bath-PUVA.” According to Dr. Hönigsmann a number of topical treatments can be combined with PUVA. “Clinical studies show an increased efficacy with vitamin D analogs, topical corticosteroids and retinoids, such as tazarotene, in combination with both UVB and PUVA.” However, he warned, many patients do not favor topical treatments. “Some patients find the therapies too time- consuming, or dislike them because they involve topical treatments, or they cannot afford the additional costs.” As far as systemic combinations, Dr. Hönigsmann said that the most effective systemic combination is PUVA with retinoids, either acitretin (Soriatane) or isotretinoin (Accutane), which are equally effective. “The combination with retinoids in a dose of about 0.5 mg/kg to 1 mg/kg reduces the cumulative UVA dose by more than 50%, and the cancer protective action of retinoids may contribute to increased safety of this combination.” He warned that PUVA combined with cyclosporin or cyclosporin after long-term PUVA (with high cumulative doses or many treatments) appears to increase the incidence of PUVA-induced squamous cell carcinomas. According to Dr. Hönigsmann, bath-PUVA can be used to treat all conditions that respond to oral PUVA, including plaque psoriasis, palmoplantar dermatoses, lichen planus, atopic dermatitis, urticaria pigmentosa, localized scleroderma, graft versus host disease, pagetoid reticulosis and mycosis fungoides. “It’s a very effective treatment, particularly for palmoplantar disease,” said Dr. Hönigsmann. “Instead of involving the entire system, the treatment requires only the immersion of hands and feet.” Dr. Hönigsmann recommends treatments two or four times weekly. Bath-PUVA is done with either 8-methoxy- psoralen or trimethylpsoralen (not available in the United States) and it can be combined with retinoids. “It’s important to have a high temperature, between 89 to 98 degrees Fahrenheit with about 0.5 mg of 8-methoxypsoralen per liter of water,” said Dr. Hönigsmann. “The patient should remain in the bath for about 15 or 20 minutes.” Because photosensitivity is up to 10 times higher than with oral-PUVA, Dr. Hönigsmann recommended that the initial PUVA dose should be 30% of the minimal phototoxicity dose, or about 0.1 J/cm2 to 1.0 J/cm2. If there is no erythema and a good response, the dose can be increased once weekly by 30%. If there’s a minimal or persistent asymptomatic erythema, then there should be no increase. If there’s painful erythema with blister formation, stop treatment. After symptoms resolve, reduce the dose by 50%, and increase it only 10% for the next treatment. With this type of therapy, the minimal phototoxicity dose may decrease during the first days after initiation of treatment by up to 50%, so monitor patients carefully. “Bath-PUVA has several advantages, including a consistent and reproducible skin photosensitization,” said Dr. Hönigsmann. “In addition, there is no systemic photosensitization, no nausea, dizziness or vomiting and no eye shielding is required.” An additional advantage that is important to many patients is that photosensitization declines rapidly and lasts not more than 2 hours. Finally, studies show that bath-PUVA carries a lower risk of squamous cell cancer. UVA-1 and Other Experimental Phototherapies Among the new phototherapies are two approaches that use a selective spectrum of radiation, one in the ultraviolet range and the other in the visible range. The goal of these approaches is to specifically target the mechanisms that sustain the dermatosis while attempting to avoid side effects by limiting the energy at other wavelengths. “The narrow-range ultraviolet, called UVA-1, can effectively treat severe forms of atopic dermatitis,” said Jean T. Krutmann, M.D., Professor of Environmental Health Research and Dermatology at the Environmental Health Research Institute at Heinrich Heine University in Germany. “We have also found that the condition can be treated using a selective spectrum within the visible range, and we have termed this therapy Dermodyne therapy.” According to Dr Krutmann, patients with severe atopic dermatitis in controlled, randomized multi-center trials showed significant improvement after treatment with UVA-1, long-wave UVA radiation in the 340 nm to 400 nm range. The most effective approach is 10 to 15 treatments of doses up to 132 J/cm2 of UVA-1. Dr. Krutmann advises that patients who are in remission or haven’t completely cleared should be moved to a less effective but safer modality such as 311 nm UVB or UVA/UVB or even broadband UVB. Atopic dermatitis isn’t the only skin disorder that responds to UVA-1 therapy. “Evidence shows that UVA-1 therapy may also be effective in treating other conditions,” said Dr. Krutmann. “Cutaneous T-cell lymphoma, dyshi-drotic hand and foot eczema, urticaria pigmentosa and scleroderma all appear to respond favorably to UVA-1 therapy.” According to Dr. Krutmann, UVA-1 has the potential to become a veritable alternative to PUVA and possibly even the therapy of choice for CTCL. Dr. Krutmann and colleagues published a paper in the February 2004 issue of the Journal of Investigative Dermatology that showed that malignant T-cells are more susceptible to UVA-1 as compared with normal T-cells. A significant problem with UV phototherapy is the real potential for cancers, especially among young patients. To address this issue, Dr. Krutmann, in collaboration with a Berlin-based biotech company for which he consults, recently developed and tested a UV-free phototherapy device for treatment of patients with atopic dermatitis. Called Dermodyne therapy, it’s based on the use of a pulsed light source with a frequency conversion. According to Dr. Krutmann, treatment time is 30 minutes per day three times per week at a pulse frequency of 0.25 Hertz and a treatment fluence of 15 J/cm2. The actual dose in the UVA range is less than 1 J/cm2. A recently completed clinical trial with 10 patients showed significant improvement after 4 weeks of treatment using the Dermodyne therapy. For this pilot study each patient was first treated with a dummy device, which did not result in any improvement, but caused one patient to dropout. This was followed by the Dermodyne therapy, which worked in all nine patients. Eight of the nine patients stayed in partial or complete remission for more than 6 months, according to Dr. Krutmann. Based on these results, researchers have initiated a controlled, randomized multicenter trial in Europe. New Approaches, Better Results The range of phototherapies that exist to treat skin disorders has never been wider, and the variety of disorders that can be treated has never been greater. New phototherapies, as well as new approaches to established therapies, offer improved performance and efficacy and can now be used to treat patients that may have been at one time considered untreatable. Combination therapies and narrowband or selected spectrum phototherapies significantly reduce the risks and side effects normally found with phototherapies. For many dermatology patients, new phototherapy treatments may bring relief from their conditions that traditional therapies could not provide. Lack of Advertising for Psoriasis Treatments Over the last several years, the use of phototherapy to treat psoriasis has decreased in the United States. According to a recent study published in Dermatology Online Journal, the reason for this decrease is due to a combination of factors, including a perceived loss of interest among dermatologists and increased co-pay costs for phototherapy visits. The authors of the study said, “While many dermatologists continue to focus on medical dermatology, changing workforce patterns and the increased breadth of surgical and cosmetic services being offered raise the possibility that patients with medical dermatologic conditions will find it increasingly difficult to access dermatological treatment.” The purpose of this study was to examine to what extent dermatologists are using the Yellow Pages to advertise to patients with psoriasis. Researchers analyzed dermatologists’ advertisements and compared psoriasis advertising to cosmetic services advertising. A quantitative and qualitative assessment of the advertisements in a random sampling of small cities and the 10 largest metropolitan regions in the country was performed. Only one company’s listing were used to limit biases between the different potential Yellow Page sources. Results Per capita, more dermatology-related advertisements were found in smaller markets than larger markets, and a higher percentage were descriptive rather than just a name, address and phone number. In the smaller markets analyzed, there were 380 ads for an estimated 13,020,400 people or 1 ad for every 34,260 people compared to 772 ads for 88,734,000 people or 1 ad for every 114,940 people in large metropolitan areas. Cosmetic and surgical advertisements were more common than psoriasis ads in both markets. The cosmetic ads were more prevalent in the larger markets. In all regions, psoriasis and psoriasis treatment ads were the least common. The study authors concluded, “These findings raise the concern that incentive structures in the United States healthcare system do not adequately support delivery of dermatologic care for psoriasis.” The authors believe that efforts to promote psoriasis care should be encouraged. Study authors: John G. Hancox, M.D., Rajesh Balkrishnan, Ph.D., Jamila Battle, B.S., Tamara Salam Housman, M.D., Alan B. Fleischer, Jr. M.D., and Steven R. Feldman, M.D., Ph.D. Fitting this Therapy into Practice By Barry I. Resnik, M.D. For about 5 years now, I have been offering patients therapy with narrowband UVB. My decision to offer phototherapy was a simple one — I wanted to treat patients with the best therapy at hand. Phototherapy is a good procedure to offer because you win and the patient wins — we have an established therapy with proven efficacy. And narrowband on the whole is a lot easier to deal with than broadband. It’s not as arcane or difficult to administer as broadband. Choosing narrowband UVB When I decided to integrate this type of therapy into my practice, I knew that I would only offer narrowband UVB therapy because I had seen the potential side effects of broadband UVB, mostly burning, first-hand. After researching the options, I ended up buying a box for about $7,000 from UVBioTek (Dr. Resnik has no financial interest in this company). I was able to get a 24-bulb box, which is considered a good healthy amount of bulbs with which to administer treatment in a short amount of time. The patient gets much less erythema. Both this company’s home and office units are low profile, and they open off the wall in a manner similar to a clamshell. The unit only protrudes about 6 to 10 inches from the wall when it’s closed. To open it, you pull it from the wall, and the patient stands in it and undergoes therapy without needing to turn around. It also blends nicely into the décor — you can choose the type of finish you want. We use this unit in a room in which we also perform endermologie. Converting from Broadband UVB to Narrowband UVB From what I’ve heard from many colleagues who’ve converted from broadband to narrowband, converting a unit hasn’t been worth the outlay of money. Converting a unit isn’t as simple as changing the light bulb. The computer controls and the whole mechanism need to be changed. In the end, it turned out to be more cost-effective to buy a new box than to upgrade an existing broadband box. Why Don’t More Dermatologists Offer This Therapy? From my own perspective, I think it’s a shame that more dermatologists don’t offer phototherapy. It works for the patient, and the doctor gets reimbursed in a fair and consistent manner. I paid for the unit I bought within a year. In addition, I had no coding curve. The same codes that I used for broadband apply for narrowband. Phototherapy may be less sexy than lasers and injectables — but it’s just a plain good therapy that a lot of dermatologists tend to overlook. Dr. Resnik is a voluntary Clinical Pro-fessor with the Department of Dermatology and Cutaneous Surgery at the University of Miami School of Medicine. He’s also in private practice in Aventura, FL.
Evaluating Options forPhototherapy
I n recent years, photomedicine, the therapeutic use of UV radiation and visible light, has become a critical weapon in the war against skin disorders. With bold, new approaches and innovative phototherapies, photomedicine now offers the promise of effectively treating the most intractable of dermatoses. Researchers and clinicians have developed a wide range of phototherapeutic techniques to treat a variety of conditions, including psoriasis, vitiligo and cutaneous T-cell lymphoma. Bath-PUVA and combinations with other topical and systemic treatment modalities can be used to either reduce side effects or enhance efficacy. Narrowband UVB and UVA-1 radiation along with selected spectra visible light are proving to be effective and potentially lower-risk alternative treatments for a wide range of dermatoses. Narrowband UVB Phototherapy Broadband UVB phototherapy (270 nm to 350 nm) is a very effective therapeutic strategy for psoriasis and other skin conditions, with a safety profile backed up by long-term follow-up studies. However, narrowband (311 nm to 313 nm) may be a better option. “Studies show that the maximum clearing occurs at 311 nm. The advantage of that is that you get rid of all the high-energy short wavelengths,” said Thomas Schwarz, M.D., Vice Chairman, Department of Dermatology, University of Muenster, Germany. “Since this is the much safer therapy, the narrowband in the long term will replace broadband in this application. I’m not aware of any study showing that the narrowband is inferior to the UVB.” According to Dr. Schwarz, another advantage to narrowband UVB is that higher energy levels can be used, resulting in greater clearing without increasing the risks and side effects. “Studies show that the minimal erythema dose (MED) for broadband is around 76 mJ/cm2, but with the 311 nm it was around 410 mJ/cm2, which is a big difference,” said Dr. Schwarz. “In addition, studies showed that while doses at 70% MED did clear faster, doses at 30% MED were equally effective and required only more sessions.” The lower MED would result in a lower total cumulative dose at the end of therapy. In his practice, Dr. Schwarz usually prescribes therapy for patients five times per week, but acknowledged that studies show that treatment three times per week may provide the best combination of timely clearing and low cumulative dosing. For narrowband treatments, Dr. Schwarz uses the Phillips TL01 bulb that has its maximum output near 311 nm. Erythema occurs within 12 hours after UVB treatment, so the next day a physician can easily see whether the dose given the day before was the appropriate one or not. Dosage can be adjusted as therapy progresses, increasing or decreasing the dose based on the level of erythema. Dr Schwarz has one caveat when using narrowband to treat a patient. “You must be careful when moving a patient from a narrowband to a broadband unit. A patient exposed to the same energy levels on the broadband unit as he or she received on the narrowband unit would suffer extreme erythema.” Conditions that Respond Best A number of skin conditions can be treated with broadband and narrowband UVB. According to Dr. Schwarz, UVB can be used for atopic dermatitis, and narrowband UVB may be the more effective phototherapy. In addition, studies show that vitiligo responds to low-dose phototherapy, especially in children. But while some studies showed repigmentation of up to 100% in some patients, most patients had unacceptable repigmentation levels. Mycosis fungoides (cutaneous T-cell lymphoma) responds well to either broadband or narrowband UVB; however, Dr. Schwarz said that PUVA therapy is as effective and may result in longer lasting remissions. Combining Therapies A number of therapies can be combined with UVB to improve the effectiveness of the therapy or reduce side effects. Studies show that if you precondition the skin with vitamin D and administer systemic retinoids for a few weeks prior to starting the UVB that you can reduce the cumulative dose. “The application of topical vitamin D after UVB treatment can improve the results of each treatment and lower the cumulative doses,” said Dr. Schwarz. “Studies have also shown that you can also combine topical retinoids such as tazarotene (Tazorac) and lower the total cumulative UV doses.” Tazarotene is photo-stable, but Dr Schwarz warned it may irritate some patients. When using tazarotene, start conservatively at the beginning of treatment and lower the dose. PUVA Photochemotherapy According to Henry W. Lim, M.D., Chairman and C. S. Livingood Chair, Department of Dermatology at Henry Ford Hospital in Detroit, a number of skin disorders, including psoriasis, vitiligo and cutaneous T-cell lymphoma, respond successfully to PUVA photochemotherapy. This therapy involves administering a psoralen followed by PUVA. Currently, the only psoralen available in the United States is 8-methoxypsoralen (8-MOP). The typical treatment cycle for 8-MOP is two or three times per week. When administered, 8-MOP is absorbed quite well with a peak photosensitization occurring between 1 to 3 hours after ingestion. “The standard regimen is to administer the 8-MOP an hour before starting treatment,” explained Dr. Lim. “Usually we start with 0.5 mg/kg to 0.6 mg/kg. 8-MOP is available in 10-mg capsules.” The peak spectral output of light used is 350 nm. For starting dose, Dr. Lim uses the skin type to guide therapy, and he suggests the following: Patients with skin type I. Start with 1 J/cm or 1.5 J/cm2. Patients with skin type III. Use 3 J/cm2 to 3.5 J/cm2. Patients with skin type VI. Use 6 J/cm2 to 6.5 J/cm2. “In terms of increment, use 0.5 J/cm2 to 1.5 J/cm2, depending on the skin type,” Dr. Lim advised. Dr. Lim warned that the photosensitivity and the serum level are both affected if the patient eats just prior to taking the medication, and he recommends low-fat meals. “The best results can be obtained by ensuring that patients maintain a consistent interval between eating and taking the psoralen and eat the same type of food each time before taking the psoralen,” said Dr. Lim. “Patients should be warned about possible photosensitivity for the day of the administration and must wear UV-protective lenses when they go outside or when near windows.” According to Dr. Lim, patients under the age of 10 should not be treated, and extreme care should be taken when treating patients between 10 and 18 years of age. Patients with a history of melanoma, lupus erythematosis, xeroderma pigmentosum, dysplastic nevi, non-melanoma skin cancer or photosensitivity, or taking medications that make them photosensitive should not be treated; nor should pregnant or nursing women. Patients undergoing treatment with cyclosporine should not have PUVA treatments. In addition, exposure to ionizing radiation, arsenical injection, tacrolimus (Protopic), pimecrolimus (Elidel) and methotrexate potentially increase PUVA photocarcinogenicity. Not only has Dr. Lim’s own experience with the therapy convinced him of its effectiveness, he also cited a number of other studies with good results. “In a U.S. study involving more than 1,100 patients, 89% cleared, typically after 25 treatments over 12 weeks,” said Dr. Lim. “A similar European study of 3,000 patients produced similar results in somewhat less time, though some of the patients had received retinoids.” PUVA can be combined with other treatments, including topical corticosteroids, anthralin (Psoriatic Cream) and calcipotriol ointment (Dovonex). At least one study suggested that a combination of PUVA plus vitamin D derivative topical or PUVA plus tazarotene topical may be more effective than PUVA alone. Systemic or topical retinoids with PUVA have been used with very good success. Multiple studies show that PUVA is a very good treatment for mycosis fungoides (cutaneous T-cell lymphoma), primarily because you can achieve remission for a consistently longer period of time than with most other treatments. PUVA has been shown to be up to 85% effective in more than 70% of patients with vitiligo of the head, neck, upper arms, legs and trunk. Patients may get complete re-pigmentation, and this area may be stable for long periods. Distal hands and feet and the lips are poorly responsive. Genital areas should be shielded. According to Dr. Lim, the most common side effects of PUVA are nausea and, less commonly, vomiting, which can be easily managed. “Several methods can control nausea,” said Dr. Lim. “Having the patient eat prior to taking the pills or having them take the pills individually over about a half an hour are simple approaches.” More persistent nausea can be treated with anti-nausea medication approximately 30 minutes prior to ingesting psoralen. Dizziness and headaches have been infrequently reported. Dr. Lim noted several side effects associated with PUVA treatments. Erythema can occur depending upon the dose and the patient’s sensitivity; it peaks between 48 and 72 hours after treatment. Skin fragility resulting in the development of friction blisters can develop. Melanonychia, especially in darker- skinned individuals, can also occur, though it resolves if you stop the PUVA. Pruritus is another acute side effect. The so-called PUVA itch is localized primarily to the mid-back, and is often severe, persistent and resistant to therapy. Photoaging can result from long-term treatment, with a majority of patients experiencing significant photoaging in exposed areas. Skin Cancer Risks According to Dr. Lim, there are significant skin cancer risks for PUVA chemotherapy. Studies show a significant increase in the risk of malignant melanoma and squamous cell carcinoma for high-dose patients (greater than 200 treatments or 2,000 J/cm2). Male genitalia appear to be especially susceptible. However, a large Swedish study involving nearly 5,000 men and women with a follow-up period of more than 15 years found no increase in melanoma. Some of the Swedish patients were treated with trimethylpsoralen (not available in the United States). PUVA Variants (Bath-PUVA, Combination Treatments) PUVA is a recognized and effective therapy for a wide range of skin disorders. Today, researchers are investigating ways of improving the therapy by combining PUVA with other treatments. “The aim of combining PUVA with other treatments is to either reduce side effects, such as prolonged photosensitivity, erythema and carcinogenesis, or to increase the efficacy of the treatment,” explained Herbert Hönigsmann, M.D., Chairman of the Division of Special and Environmental Dermatology at the University of Vienna Medical School in Austria. “Typical combined PUVA therapies include PUVA with topical therapy, PUVA with systemic therapy and topical bath-PUVA.” According to Dr. Hönigsmann a number of topical treatments can be combined with PUVA. “Clinical studies show an increased efficacy with vitamin D analogs, topical corticosteroids and retinoids, such as tazarotene, in combination with both UVB and PUVA.” However, he warned, many patients do not favor topical treatments. “Some patients find the therapies too time- consuming, or dislike them because they involve topical treatments, or they cannot afford the additional costs.” As far as systemic combinations, Dr. Hönigsmann said that the most effective systemic combination is PUVA with retinoids, either acitretin (Soriatane) or isotretinoin (Accutane), which are equally effective. “The combination with retinoids in a dose of about 0.5 mg/kg to 1 mg/kg reduces the cumulative UVA dose by more than 50%, and the cancer protective action of retinoids may contribute to increased safety of this combination.” He warned that PUVA combined with cyclosporin or cyclosporin after long-term PUVA (with high cumulative doses or many treatments) appears to increase the incidence of PUVA-induced squamous cell carcinomas. According to Dr. Hönigsmann, bath-PUVA can be used to treat all conditions that respond to oral PUVA, including plaque psoriasis, palmoplantar dermatoses, lichen planus, atopic dermatitis, urticaria pigmentosa, localized scleroderma, graft versus host disease, pagetoid reticulosis and mycosis fungoides. “It’s a very effective treatment, particularly for palmoplantar disease,” said Dr. Hönigsmann. “Instead of involving the entire system, the treatment requires only the immersion of hands and feet.” Dr. Hönigsmann recommends treatments two or four times weekly. Bath-PUVA is done with either 8-methoxy- psoralen or trimethylpsoralen (not available in the United States) and it can be combined with retinoids. “It’s important to have a high temperature, between 89 to 98 degrees Fahrenheit with about 0.5 mg of 8-methoxypsoralen per liter of water,” said Dr. Hönigsmann. “The patient should remain in the bath for about 15 or 20 minutes.” Because photosensitivity is up to 10 times higher than with oral-PUVA, Dr. Hönigsmann recommended that the initial PUVA dose should be 30% of the minimal phototoxicity dose, or about 0.1 J/cm2 to 1.0 J/cm2. If there is no erythema and a good response, the dose can be increased once weekly by 30%. If there’s a minimal or persistent asymptomatic erythema, then there should be no increase. If there’s painful erythema with blister formation, stop treatment. After symptoms resolve, reduce the dose by 50%, and increase it only 10% for the next treatment. With this type of therapy, the minimal phototoxicity dose may decrease during the first days after initiation of treatment by up to 50%, so monitor patients carefully. “Bath-PUVA has several advantages, including a consistent and reproducible skin photosensitization,” said Dr. Hönigsmann. “In addition, there is no systemic photosensitization, no nausea, dizziness or vomiting and no eye shielding is required.” An additional advantage that is important to many patients is that photosensitization declines rapidly and lasts not more than 2 hours. Finally, studies show that bath-PUVA carries a lower risk of squamous cell cancer. UVA-1 and Other Experimental Phototherapies Among the new phototherapies are two approaches that use a selective spectrum of radiation, one in the ultraviolet range and the other in the visible range. The goal of these approaches is to specifically target the mechanisms that sustain the dermatosis while attempting to avoid side effects by limiting the energy at other wavelengths. “The narrow-range ultraviolet, called UVA-1, can effectively treat severe forms of atopic dermatitis,” said Jean T. Krutmann, M.D., Professor of Environmental Health Research and Dermatology at the Environmental Health Research Institute at Heinrich Heine University in Germany. “We have also found that the condition can be treated using a selective spectrum within the visible range, and we have termed this therapy Dermodyne therapy.” According to Dr Krutmann, patients with severe atopic dermatitis in controlled, randomized multi-center trials showed significant improvement after treatment with UVA-1, long-wave UVA radiation in the 340 nm to 400 nm range. The most effective approach is 10 to 15 treatments of doses up to 132 J/cm2 of UVA-1. Dr. Krutmann advises that patients who are in remission or haven’t completely cleared should be moved to a less effective but safer modality such as 311 nm UVB or UVA/UVB or even broadband UVB. Atopic dermatitis isn’t the only skin disorder that responds to UVA-1 therapy. “Evidence shows that UVA-1 therapy may also be effective in treating other conditions,” said Dr. Krutmann. “Cutaneous T-cell lymphoma, dyshi-drotic hand and foot eczema, urticaria pigmentosa and scleroderma all appear to respond favorably to UVA-1 therapy.” According to Dr. Krutmann, UVA-1 has the potential to become a veritable alternative to PUVA and possibly even the therapy of choice for CTCL. Dr. Krutmann and colleagues published a paper in the February 2004 issue of the Journal of Investigative Dermatology that showed that malignant T-cells are more susceptible to UVA-1 as compared with normal T-cells. A significant problem with UV phototherapy is the real potential for cancers, especially among young patients. To address this issue, Dr. Krutmann, in collaboration with a Berlin-based biotech company for which he consults, recently developed and tested a UV-free phototherapy device for treatment of patients with atopic dermatitis. Called Dermodyne therapy, it’s based on the use of a pulsed light source with a frequency conversion. According to Dr. Krutmann, treatment time is 30 minutes per day three times per week at a pulse frequency of 0.25 Hertz and a treatment fluence of 15 J/cm2. The actual dose in the UVA range is less than 1 J/cm2. A recently completed clinical trial with 10 patients showed significant improvement after 4 weeks of treatment using the Dermodyne therapy. For this pilot study each patient was first treated with a dummy device, which did not result in any improvement, but caused one patient to dropout. This was followed by the Dermodyne therapy, which worked in all nine patients. Eight of the nine patients stayed in partial or complete remission for more than 6 months, according to Dr. Krutmann. Based on these results, researchers have initiated a controlled, randomized multicenter trial in Europe. New Approaches, Better Results The range of phototherapies that exist to treat skin disorders has never been wider, and the variety of disorders that can be treated has never been greater. New phototherapies, as well as new approaches to established therapies, offer improved performance and efficacy and can now be used to treat patients that may have been at one time considered untreatable. Combination therapies and narrowband or selected spectrum phototherapies significantly reduce the risks and side effects normally found with phototherapies. For many dermatology patients, new phototherapy treatments may bring relief from their conditions that traditional therapies could not provide. Lack of Advertising for Psoriasis Treatments Over the last several years, the use of phototherapy to treat psoriasis has decreased in the United States. According to a recent study published in Dermatology Online Journal, the reason for this decrease is due to a combination of factors, including a perceived loss of interest among dermatologists and increased co-pay costs for phototherapy visits. The authors of the study said, “While many dermatologists continue to focus on medical dermatology, changing workforce patterns and the increased breadth of surgical and cosmetic services being offered raise the possibility that patients with medical dermatologic conditions will find it increasingly difficult to access dermatological treatment.” The purpose of this study was to examine to what extent dermatologists are using the Yellow Pages to advertise to patients with psoriasis. Researchers analyzed dermatologists’ advertisements and compared psoriasis advertising to cosmetic services advertising. A quantitative and qualitative assessment of the advertisements in a random sampling of small cities and the 10 largest metropolitan regions in the country was performed. Only one company’s listing were used to limit biases between the different potential Yellow Page sources. Results Per capita, more dermatology-related advertisements were found in smaller markets than larger markets, and a higher percentage were descriptive rather than just a name, address and phone number. In the smaller markets analyzed, there were 380 ads for an estimated 13,020,400 people or 1 ad for every 34,260 people compared to 772 ads for 88,734,000 people or 1 ad for every 114,940 people in large metropolitan areas. Cosmetic and surgical advertisements were more common than psoriasis ads in both markets. The cosmetic ads were more prevalent in the larger markets. In all regions, psoriasis and psoriasis treatment ads were the least common. The study authors concluded, “These findings raise the concern that incentive structures in the United States healthcare system do not adequately support delivery of dermatologic care for psoriasis.” The authors believe that efforts to promote psoriasis care should be encouraged. Study authors: John G. Hancox, M.D., Rajesh Balkrishnan, Ph.D., Jamila Battle, B.S., Tamara Salam Housman, M.D., Alan B. Fleischer, Jr. M.D., and Steven R. Feldman, M.D., Ph.D. Fitting this Therapy into Practice By Barry I. Resnik, M.D. For about 5 years now, I have been offering patients therapy with narrowband UVB. My decision to offer phototherapy was a simple one — I wanted to treat patients with the best therapy at hand. Phototherapy is a good procedure to offer because you win and the patient wins — we have an established therapy with proven efficacy. And narrowband on the whole is a lot easier to deal with than broadband. It’s not as arcane or difficult to administer as broadband. Choosing narrowband UVB When I decided to integrate this type of therapy into my practice, I knew that I would only offer narrowband UVB therapy because I had seen the potential side effects of broadband UVB, mostly burning, first-hand. After researching the options, I ended up buying a box for about $7,000 from UVBioTek (Dr. Resnik has no financial interest in this company). I was able to get a 24-bulb box, which is considered a good healthy amount of bulbs with which to administer treatment in a short amount of time. The patient gets much less erythema. Both this company’s home and office units are low profile, and they open off the wall in a manner similar to a clamshell. The unit only protrudes about 6 to 10 inches from the wall when it’s closed. To open it, you pull it from the wall, and the patient stands in it and undergoes therapy without needing to turn around. It also blends nicely into the décor — you can choose the type of finish you want. We use this unit in a room in which we also perform endermologie. Converting from Broadband UVB to Narrowband UVB From what I’ve heard from many colleagues who’ve converted from broadband to narrowband, converting a unit hasn’t been worth the outlay of money. Converting a unit isn’t as simple as changing the light bulb. The computer controls and the whole mechanism need to be changed. In the end, it turned out to be more cost-effective to buy a new box than to upgrade an existing broadband box. Why Don’t More Dermatologists Offer This Therapy? From my own perspective, I think it’s a shame that more dermatologists don’t offer phototherapy. It works for the patient, and the doctor gets reimbursed in a fair and consistent manner. I paid for the unit I bought within a year. In addition, I had no coding curve. The same codes that I used for broadband apply for narrowband. Phototherapy may be less sexy than lasers and injectables — but it’s just a plain good therapy that a lot of dermatologists tend to overlook. Dr. Resnik is a voluntary Clinical Pro-fessor with the Department of Dermatology and Cutaneous Surgery at the University of Miami School of Medicine. He’s also in private practice in Aventura, FL.
I n recent years, photomedicine, the therapeutic use of UV radiation and visible light, has become a critical weapon in the war against skin disorders. With bold, new approaches and innovative phototherapies, photomedicine now offers the promise of effectively treating the most intractable of dermatoses. Researchers and clinicians have developed a wide range of phototherapeutic techniques to treat a variety of conditions, including psoriasis, vitiligo and cutaneous T-cell lymphoma. Bath-PUVA and combinations with other topical and systemic treatment modalities can be used to either reduce side effects or enhance efficacy. Narrowband UVB and UVA-1 radiation along with selected spectra visible light are proving to be effective and potentially lower-risk alternative treatments for a wide range of dermatoses. Narrowband UVB Phototherapy Broadband UVB phototherapy (270 nm to 350 nm) is a very effective therapeutic strategy for psoriasis and other skin conditions, with a safety profile backed up by long-term follow-up studies. However, narrowband (311 nm to 313 nm) may be a better option. “Studies show that the maximum clearing occurs at 311 nm. The advantage of that is that you get rid of all the high-energy short wavelengths,” said Thomas Schwarz, M.D., Vice Chairman, Department of Dermatology, University of Muenster, Germany. “Since this is the much safer therapy, the narrowband in the long term will replace broadband in this application. I’m not aware of any study showing that the narrowband is inferior to the UVB.” According to Dr. Schwarz, another advantage to narrowband UVB is that higher energy levels can be used, resulting in greater clearing without increasing the risks and side effects. “Studies show that the minimal erythema dose (MED) for broadband is around 76 mJ/cm2, but with the 311 nm it was around 410 mJ/cm2, which is a big difference,” said Dr. Schwarz. “In addition, studies showed that while doses at 70% MED did clear faster, doses at 30% MED were equally effective and required only more sessions.” The lower MED would result in a lower total cumulative dose at the end of therapy. In his practice, Dr. Schwarz usually prescribes therapy for patients five times per week, but acknowledged that studies show that treatment three times per week may provide the best combination of timely clearing and low cumulative dosing. For narrowband treatments, Dr. Schwarz uses the Phillips TL01 bulb that has its maximum output near 311 nm. Erythema occurs within 12 hours after UVB treatment, so the next day a physician can easily see whether the dose given the day before was the appropriate one or not. Dosage can be adjusted as therapy progresses, increasing or decreasing the dose based on the level of erythema. Dr Schwarz has one caveat when using narrowband to treat a patient. “You must be careful when moving a patient from a narrowband to a broadband unit. A patient exposed to the same energy levels on the broadband unit as he or she received on the narrowband unit would suffer extreme erythema.” Conditions that Respond Best A number of skin conditions can be treated with broadband and narrowband UVB. According to Dr. Schwarz, UVB can be used for atopic dermatitis, and narrowband UVB may be the more effective phototherapy. In addition, studies show that vitiligo responds to low-dose phototherapy, especially in children. But while some studies showed repigmentation of up to 100% in some patients, most patients had unacceptable repigmentation levels. Mycosis fungoides (cutaneous T-cell lymphoma) responds well to either broadband or narrowband UVB; however, Dr. Schwarz said that PUVA therapy is as effective and may result in longer lasting remissions. Combining Therapies A number of therapies can be combined with UVB to improve the effectiveness of the therapy or reduce side effects. Studies show that if you precondition the skin with vitamin D and administer systemic retinoids for a few weeks prior to starting the UVB that you can reduce the cumulative dose. “The application of topical vitamin D after UVB treatment can improve the results of each treatment and lower the cumulative doses,” said Dr. Schwarz. “Studies have also shown that you can also combine topical retinoids such as tazarotene (Tazorac) and lower the total cumulative UV doses.” Tazarotene is photo-stable, but Dr Schwarz warned it may irritate some patients. When using tazarotene, start conservatively at the beginning of treatment and lower the dose. PUVA Photochemotherapy According to Henry W. Lim, M.D., Chairman and C. S. Livingood Chair, Department of Dermatology at Henry Ford Hospital in Detroit, a number of skin disorders, including psoriasis, vitiligo and cutaneous T-cell lymphoma, respond successfully to PUVA photochemotherapy. This therapy involves administering a psoralen followed by PUVA. Currently, the only psoralen available in the United States is 8-methoxypsoralen (8-MOP). The typical treatment cycle for 8-MOP is two or three times per week. When administered, 8-MOP is absorbed quite well with a peak photosensitization occurring between 1 to 3 hours after ingestion. “The standard regimen is to administer the 8-MOP an hour before starting treatment,” explained Dr. Lim. “Usually we start with 0.5 mg/kg to 0.6 mg/kg. 8-MOP is available in 10-mg capsules.” The peak spectral output of light used is 350 nm. For starting dose, Dr. Lim uses the skin type to guide therapy, and he suggests the following: Patients with skin type I. Start with 1 J/cm or 1.5 J/cm2. Patients with skin type III. Use 3 J/cm2 to 3.5 J/cm2. Patients with skin type VI. Use 6 J/cm2 to 6.5 J/cm2. “In terms of increment, use 0.5 J/cm2 to 1.5 J/cm2, depending on the skin type,” Dr. Lim advised. Dr. Lim warned that the photosensitivity and the serum level are both affected if the patient eats just prior to taking the medication, and he recommends low-fat meals. “The best results can be obtained by ensuring that patients maintain a consistent interval between eating and taking the psoralen and eat the same type of food each time before taking the psoralen,” said Dr. Lim. “Patients should be warned about possible photosensitivity for the day of the administration and must wear UV-protective lenses when they go outside or when near windows.” According to Dr. Lim, patients under the age of 10 should not be treated, and extreme care should be taken when treating patients between 10 and 18 years of age. Patients with a history of melanoma, lupus erythematosis, xeroderma pigmentosum, dysplastic nevi, non-melanoma skin cancer or photosensitivity, or taking medications that make them photosensitive should not be treated; nor should pregnant or nursing women. Patients undergoing treatment with cyclosporine should not have PUVA treatments. In addition, exposure to ionizing radiation, arsenical injection, tacrolimus (Protopic), pimecrolimus (Elidel) and methotrexate potentially increase PUVA photocarcinogenicity. Not only has Dr. Lim’s own experience with the therapy convinced him of its effectiveness, he also cited a number of other studies with good results. “In a U.S. study involving more than 1,100 patients, 89% cleared, typically after 25 treatments over 12 weeks,” said Dr. Lim. “A similar European study of 3,000 patients produced similar results in somewhat less time, though some of the patients had received retinoids.” PUVA can be combined with other treatments, including topical corticosteroids, anthralin (Psoriatic Cream) and calcipotriol ointment (Dovonex). At least one study suggested that a combination of PUVA plus vitamin D derivative topical or PUVA plus tazarotene topical may be more effective than PUVA alone. Systemic or topical retinoids with PUVA have been used with very good success. Multiple studies show that PUVA is a very good treatment for mycosis fungoides (cutaneous T-cell lymphoma), primarily because you can achieve remission for a consistently longer period of time than with most other treatments. PUVA has been shown to be up to 85% effective in more than 70% of patients with vitiligo of the head, neck, upper arms, legs and trunk. Patients may get complete re-pigmentation, and this area may be stable for long periods. Distal hands and feet and the lips are poorly responsive. Genital areas should be shielded. According to Dr. Lim, the most common side effects of PUVA are nausea and, less commonly, vomiting, which can be easily managed. “Several methods can control nausea,” said Dr. Lim. “Having the patient eat prior to taking the pills or having them take the pills individually over about a half an hour are simple approaches.” More persistent nausea can be treated with anti-nausea medication approximately 30 minutes prior to ingesting psoralen. Dizziness and headaches have been infrequently reported. Dr. Lim noted several side effects associated with PUVA treatments. Erythema can occur depending upon the dose and the patient’s sensitivity; it peaks between 48 and 72 hours after treatment. Skin fragility resulting in the development of friction blisters can develop. Melanonychia, especially in darker- skinned individuals, can also occur, though it resolves if you stop the PUVA. Pruritus is another acute side effect. The so-called PUVA itch is localized primarily to the mid-back, and is often severe, persistent and resistant to therapy. Photoaging can result from long-term treatment, with a majority of patients experiencing significant photoaging in exposed areas. Skin Cancer Risks According to Dr. Lim, there are significant skin cancer risks for PUVA chemotherapy. Studies show a significant increase in the risk of malignant melanoma and squamous cell carcinoma for high-dose patients (greater than 200 treatments or 2,000 J/cm2). Male genitalia appear to be especially susceptible. However, a large Swedish study involving nearly 5,000 men and women with a follow-up period of more than 15 years found no increase in melanoma. Some of the Swedish patients were treated with trimethylpsoralen (not available in the United States). PUVA Variants (Bath-PUVA, Combination Treatments) PUVA is a recognized and effective therapy for a wide range of skin disorders. Today, researchers are investigating ways of improving the therapy by combining PUVA with other treatments. “The aim of combining PUVA with other treatments is to either reduce side effects, such as prolonged photosensitivity, erythema and carcinogenesis, or to increase the efficacy of the treatment,” explained Herbert Hönigsmann, M.D., Chairman of the Division of Special and Environmental Dermatology at the University of Vienna Medical School in Austria. “Typical combined PUVA therapies include PUVA with topical therapy, PUVA with systemic therapy and topical bath-PUVA.” According to Dr. Hönigsmann a number of topical treatments can be combined with PUVA. “Clinical studies show an increased efficacy with vitamin D analogs, topical corticosteroids and retinoids, such as tazarotene, in combination with both UVB and PUVA.” However, he warned, many patients do not favor topical treatments. “Some patients find the therapies too time- consuming, or dislike them because they involve topical treatments, or they cannot afford the additional costs.” As far as systemic combinations, Dr. Hönigsmann said that the most effective systemic combination is PUVA with retinoids, either acitretin (Soriatane) or isotretinoin (Accutane), which are equally effective. “The combination with retinoids in a dose of about 0.5 mg/kg to 1 mg/kg reduces the cumulative UVA dose by more than 50%, and the cancer protective action of retinoids may contribute to increased safety of this combination.” He warned that PUVA combined with cyclosporin or cyclosporin after long-term PUVA (with high cumulative doses or many treatments) appears to increase the incidence of PUVA-induced squamous cell carcinomas. According to Dr. Hönigsmann, bath-PUVA can be used to treat all conditions that respond to oral PUVA, including plaque psoriasis, palmoplantar dermatoses, lichen planus, atopic dermatitis, urticaria pigmentosa, localized scleroderma, graft versus host disease, pagetoid reticulosis and mycosis fungoides. “It’s a very effective treatment, particularly for palmoplantar disease,” said Dr. Hönigsmann. “Instead of involving the entire system, the treatment requires only the immersion of hands and feet.” Dr. Hönigsmann recommends treatments two or four times weekly. Bath-PUVA is done with either 8-methoxy- psoralen or trimethylpsoralen (not available in the United States) and it can be combined with retinoids. “It’s important to have a high temperature, between 89 to 98 degrees Fahrenheit with about 0.5 mg of 8-methoxypsoralen per liter of water,” said Dr. Hönigsmann. “The patient should remain in the bath for about 15 or 20 minutes.” Because photosensitivity is up to 10 times higher than with oral-PUVA, Dr. Hönigsmann recommended that the initial PUVA dose should be 30% of the minimal phototoxicity dose, or about 0.1 J/cm2 to 1.0 J/cm2. If there is no erythema and a good response, the dose can be increased once weekly by 30%. If there’s a minimal or persistent asymptomatic erythema, then there should be no increase. If there’s painful erythema with blister formation, stop treatment. After symptoms resolve, reduce the dose by 50%, and increase it only 10% for the next treatment. With this type of therapy, the minimal phototoxicity dose may decrease during the first days after initiation of treatment by up to 50%, so monitor patients carefully. “Bath-PUVA has several advantages, including a consistent and reproducible skin photosensitization,” said Dr. Hönigsmann. “In addition, there is no systemic photosensitization, no nausea, dizziness or vomiting and no eye shielding is required.” An additional advantage that is important to many patients is that photosensitization declines rapidly and lasts not more than 2 hours. Finally, studies show that bath-PUVA carries a lower risk of squamous cell cancer. UVA-1 and Other Experimental Phototherapies Among the new phototherapies are two approaches that use a selective spectrum of radiation, one in the ultraviolet range and the other in the visible range. The goal of these approaches is to specifically target the mechanisms that sustain the dermatosis while attempting to avoid side effects by limiting the energy at other wavelengths. “The narrow-range ultraviolet, called UVA-1, can effectively treat severe forms of atopic dermatitis,” said Jean T. Krutmann, M.D., Professor of Environmental Health Research and Dermatology at the Environmental Health Research Institute at Heinrich Heine University in Germany. “We have also found that the condition can be treated using a selective spectrum within the visible range, and we have termed this therapy Dermodyne therapy.” According to Dr Krutmann, patients with severe atopic dermatitis in controlled, randomized multi-center trials showed significant improvement after treatment with UVA-1, long-wave UVA radiation in the 340 nm to 400 nm range. The most effective approach is 10 to 15 treatments of doses up to 132 J/cm2 of UVA-1. Dr. Krutmann advises that patients who are in remission or haven’t completely cleared should be moved to a less effective but safer modality such as 311 nm UVB or UVA/UVB or even broadband UVB. Atopic dermatitis isn’t the only skin disorder that responds to UVA-1 therapy. “Evidence shows that UVA-1 therapy may also be effective in treating other conditions,” said Dr. Krutmann. “Cutaneous T-cell lymphoma, dyshi-drotic hand and foot eczema, urticaria pigmentosa and scleroderma all appear to respond favorably to UVA-1 therapy.” According to Dr. Krutmann, UVA-1 has the potential to become a veritable alternative to PUVA and possibly even the therapy of choice for CTCL. Dr. Krutmann and colleagues published a paper in the February 2004 issue of the Journal of Investigative Dermatology that showed that malignant T-cells are more susceptible to UVA-1 as compared with normal T-cells. A significant problem with UV phototherapy is the real potential for cancers, especially among young patients. To address this issue, Dr. Krutmann, in collaboration with a Berlin-based biotech company for which he consults, recently developed and tested a UV-free phototherapy device for treatment of patients with atopic dermatitis. Called Dermodyne therapy, it’s based on the use of a pulsed light source with a frequency conversion. According to Dr. Krutmann, treatment time is 30 minutes per day three times per week at a pulse frequency of 0.25 Hertz and a treatment fluence of 15 J/cm2. The actual dose in the UVA range is less than 1 J/cm2. A recently completed clinical trial with 10 patients showed significant improvement after 4 weeks of treatment using the Dermodyne therapy. For this pilot study each patient was first treated with a dummy device, which did not result in any improvement, but caused one patient to dropout. This was followed by the Dermodyne therapy, which worked in all nine patients. Eight of the nine patients stayed in partial or complete remission for more than 6 months, according to Dr. Krutmann. Based on these results, researchers have initiated a controlled, randomized multicenter trial in Europe. New Approaches, Better Results The range of phototherapies that exist to treat skin disorders has never been wider, and the variety of disorders that can be treated has never been greater. New phototherapies, as well as new approaches to established therapies, offer improved performance and efficacy and can now be used to treat patients that may have been at one time considered untreatable. Combination therapies and narrowband or selected spectrum phototherapies significantly reduce the risks and side effects normally found with phototherapies. For many dermatology patients, new phototherapy treatments may bring relief from their conditions that traditional therapies could not provide. Lack of Advertising for Psoriasis Treatments Over the last several years, the use of phototherapy to treat psoriasis has decreased in the United States. According to a recent study published in Dermatology Online Journal, the reason for this decrease is due to a combination of factors, including a perceived loss of interest among dermatologists and increased co-pay costs for phototherapy visits. The authors of the study said, “While many dermatologists continue to focus on medical dermatology, changing workforce patterns and the increased breadth of surgical and cosmetic services being offered raise the possibility that patients with medical dermatologic conditions will find it increasingly difficult to access dermatological treatment.” The purpose of this study was to examine to what extent dermatologists are using the Yellow Pages to advertise to patients with psoriasis. Researchers analyzed dermatologists’ advertisements and compared psoriasis advertising to cosmetic services advertising. A quantitative and qualitative assessment of the advertisements in a random sampling of small cities and the 10 largest metropolitan regions in the country was performed. Only one company’s listing were used to limit biases between the different potential Yellow Page sources. Results Per capita, more dermatology-related advertisements were found in smaller markets than larger markets, and a higher percentage were descriptive rather than just a name, address and phone number. In the smaller markets analyzed, there were 380 ads for an estimated 13,020,400 people or 1 ad for every 34,260 people compared to 772 ads for 88,734,000 people or 1 ad for every 114,940 people in large metropolitan areas. Cosmetic and surgical advertisements were more common than psoriasis ads in both markets. The cosmetic ads were more prevalent in the larger markets. In all regions, psoriasis and psoriasis treatment ads were the least common. The study authors concluded, “These findings raise the concern that incentive structures in the United States healthcare system do not adequately support delivery of dermatologic care for psoriasis.” The authors believe that efforts to promote psoriasis care should be encouraged. Study authors: John G. Hancox, M.D., Rajesh Balkrishnan, Ph.D., Jamila Battle, B.S., Tamara Salam Housman, M.D., Alan B. Fleischer, Jr. M.D., and Steven R. Feldman, M.D., Ph.D. Fitting this Therapy into Practice By Barry I. Resnik, M.D. For about 5 years now, I have been offering patients therapy with narrowband UVB. My decision to offer phototherapy was a simple one — I wanted to treat patients with the best therapy at hand. Phototherapy is a good procedure to offer because you win and the patient wins — we have an established therapy with proven efficacy. And narrowband on the whole is a lot easier to deal with than broadband. It’s not as arcane or difficult to administer as broadband. Choosing narrowband UVB When I decided to integrate this type of therapy into my practice, I knew that I would only offer narrowband UVB therapy because I had seen the potential side effects of broadband UVB, mostly burning, first-hand. After researching the options, I ended up buying a box for about $7,000 from UVBioTek (Dr. Resnik has no financial interest in this company). I was able to get a 24-bulb box, which is considered a good healthy amount of bulbs with which to administer treatment in a short amount of time. The patient gets much less erythema. Both this company’s home and office units are low profile, and they open off the wall in a manner similar to a clamshell. The unit only protrudes about 6 to 10 inches from the wall when it’s closed. To open it, you pull it from the wall, and the patient stands in it and undergoes therapy without needing to turn around. It also blends nicely into the décor — you can choose the type of finish you want. We use this unit in a room in which we also perform endermologie. Converting from Broadband UVB to Narrowband UVB From what I’ve heard from many colleagues who’ve converted from broadband to narrowband, converting a unit hasn’t been worth the outlay of money. Converting a unit isn’t as simple as changing the light bulb. The computer controls and the whole mechanism need to be changed. In the end, it turned out to be more cost-effective to buy a new box than to upgrade an existing broadband box. Why Don’t More Dermatologists Offer This Therapy? From my own perspective, I think it’s a shame that more dermatologists don’t offer phototherapy. It works for the patient, and the doctor gets reimbursed in a fair and consistent manner. I paid for the unit I bought within a year. In addition, I had no coding curve. The same codes that I used for broadband apply for narrowband. Phototherapy may be less sexy than lasers and injectables — but it’s just a plain good therapy that a lot of dermatologists tend to overlook. Dr. Resnik is a voluntary Clinical Pro-fessor with the Department of Dermatology and Cutaneous Surgery at the University of Miami School of Medicine. He’s also in private practice in Aventura, FL.
