11 PROTOCOL NO. 11: Psoracomb (UVB TL01) protocol PROTOCOL NO. 12: MPD protocol 23 Appendix 25

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1 Classification: Policy Lead Author: Tsui Ling Consultant Dermatologist, Clinical Additional author(s): N/A Authors Division: Dermatology Unique ID: GSCDerm02(13) Issue number: 3 Expiry Date: September 2018 Contents Section Page Intro Who should read this document 3 Key practice points 3 Policy TREATMENT PROTOCOL No. 1: Narrowband UVB (TL-01) 4 Phototherapy 2 TREATMENT PROTOCOL No. 2: Systemic PUVA Phototherapy 7 3 TREATMENT PROTOCOL No. 3: Hand and foot PUVA soaks 11 4 TREATMENT PROTOCOL No. 4: Hand and foot oral PUVA 13 5 TREATMENT PROTOCOL No. 5: Bath PUVA Phototherapy 16 6 TREATMENT PROTOCOL No. 6: Missed treatments for UVB, 18 PUVA, hand and foot PUVA 7 TREATMENT PROTOCOL No. 7: Accidental overdose UV 19 protocol 8 TREATMENT PROTOCOL No. 8: Protocol for management of 20 minor adverse events 9 PROTOCOL NO. 9: MED tester protocol PROTOCOL NO. 10: Discharge protocol 11 PROTOCOL NO. 11: Psoracomb (UVB TL01) protocol PROTOCOL NO. 12: MPD protocol 23 Appendix 25 Document control information (Published as separate document) Document Control 26 Policy Implementation Plan 27 Monitoring and Review 27 Endorsement 27 Equality analysis 28 Page 1 of 24

2 Who should read this document? Phototherapy Unit staff All Dermatology Staff All medical and nursing staff involved in the care of Phototherapy patients Key Practice Points Phototherapy protocols (UVB, PUVA, bath PUVA, hand and foot oral PUVA, hand and foot PUVA soaks, psoracomb), including incremental regimes, are shown. Protocol for management for missed treatments is listed. Protocol for management of accidental UV burns is listed. Protocol for management of minor adverse events is listed. Protocol for use of MED tester is listed. What is new in this version? PROTOCOL no. 10: Psoracomb protocol added. PROTOCOL no. 11: MPD protocol added. Body Surface area normogram removed since body surface area can be readily obtained from EPR. Page 2 of 24

3 Treatment Protocol TREATMENT PROTOCOL No. 1: Narrowband UVB (TL-01) Phototherapy 1. Initial irradiation dose: Determine MED (minimal erythema dose) with readings at 24 hours, +/- 3 hours (see Protocol no.9: Narrowband UVB MED testing), except for vitiligo patients or where the patient s skin condition or other circumstances makes testing impractical. 2. Initial irradiation dose: 70% of MED 3. NBUVB to be given three times weekly for most cases, with 2 days between treatments. 4. All patients to wear UV opaque goggles in the cabin. A face shield should also be worn unless significant lesions on face. Males must wear a sock for genital protection. 5. Incremental regime and action to be taken: see also TL01 UVB whole body cabins dose schedule Grade Definition Action E0 No erythema and no report 20% increment of erythema after last treatment E0+1 Patient reports erythema 20% increment but if previous E0+ after last treatment but now then hold dose or 10% increment resolved E1 (mild) Barely perceptible Repeat previous dose then consider E2 (moderate) E3 (severe) E4 (very severe) asymptomatic erythema Well-defined erythema, possibly causing slight manageable discomfort Well-defined symptomatic/painful erythema Painful erythema usually with blistering 10% increments Postpone one treatment if not completely settled; if settled, repeat previous dose and thereafter consider 10% increments No treatment and reviewed by Doctor when possible. When completely settled, 50% of previous dose and then 10% increments No treatment and review by Doctor Page 3 of 24

4 6. Usual course: treatments. Maximum number of treatments per course: 30. Maximum dose per treatment: 4.3 J/cm 2. Lifetime limit of 300 treatments. 7. If develop small areas of erythema: repeat previous dose and apply high factor sunscreen to affected area for one treatment. 8. If develop facial erythema or unacceptable facial pigmentation, a face shield or sunscreen should be used for each treatment. 9. If develop pruritus: encourage use of emollients and antihistamines. 10. If develop Polymorphic Light Eruption (PLE): treat with emollients and very potent topical steroids (eg. Dermovate) immediately after treatment. Postpone treatment if troublesome and reduce to 10 % increments. 11. Cancellation/ missed treatments: see missed treatment protocol. 12. Discharge: see discharge protocol. 13. Documentation: Copies of Treatment summary to be sent to responsible consultant and entered on EPR. 14. Eczema UVB Initiating dose: 0.20J/cm End of phototherapy course taper treatment, with 20% reduction in dose for each treatment: -use last dose at 2/week for 6 weeks, -followed by at 1/week for 6 weeks, -then discharge. 15. Vitiligo UVB Initiating dose dose: 0.20J/cm UVB increment: 10% Minimum 3 monthly treatment. If no response discontinue Follow up by doctor every 3 months Maximum 12 months treatment Clinical photographs at the start of treatment and every three months. 16. Polymorphic Light Eruption (or other photosensitivity disorder) UVB Initiating dose: 0.20J/cm UVB increment: 20% /week for 5 weeks, i.e. 15 treatments in total If develop PLE during treatment, Page 4 of 24

5 -If mild, continue with treatment in combination with emollients and topical steroids (eg. Dermovate ointment for body, Eumovate for face). -If severe, treat with emollients and topical steroids AND stop treatment until rash clears, then recommence at a lower dose. -Very severe flares may require oral prednisolone discuss with doctor /book into clinic Encourage patients to keep their sun tolerance topped-up by regular sun exposure throughout spring/summer. 17. Mycosis Fungoides UVB initiating dose and incremental doses: as with standard protocol UVB suitable for patch stage MF (systemic PUVA for plaque stage MF) Continue until skin clear no limit to number of treatments each course or lifetime If maintenance phototherapy is required once skin is clear, consider 1/week or less. Review every 20 maintenance treatments. Page 5 of 24

6 TREATMENT PROTOCOL No. 2: Systemic PUVA Phototherapy 1. Initial irradiation dose: Skin phototype Start dose J/cm 2 I (Always burn, never tan) 0.5 II (Usually burn, sometimes tan) 1.0 III (Usually tan, sometimes burn) 1.4 IV (Never burn, always tan) 2.0 V (Brown skin) 2.0 VI (Black skin) PUVA to be given twice weekly for most cases, with 3 days between treatments Methoxypsoralen (8-MOP) tablets are to be taken 2 hours before irradiation. The dose is calculated according to body surface area(m 2 ) (refer EPR / patient information/ body surface area). Dose of 8 MOP is 25 mg/m 2 ; dose of 5-MOP is 50 mg/m All patients to wear UV opaque goggles in the cabin. A face shield should also be worn unless significant lesions on face. Males must wear a sock for genital protection. 4. Incremental regime and action to be taken: Grade Definition Action E0 No erythema and no report of erythema after last treatment E0+1 Patient reports erythema after last treatment but now resolved E1 (mild) Barely perceptible asymptomatic erythema E2 Well-defined erythema, (moderate) E3 (severe) E4 (very severe) possibly causing slight manageable discomfort Well-defined symptomatic/painful erythema Painful erythema usually with blistering 40% increment; for 1/week treatment use 20% 40% increment but if previous E0+ then hold dose or 20% increment Repeat previous dose then consider 20% increments Postpone one treatment if not completely settled; if settled, repeat previous dose and thereafter consider 20% increments No treatment and reviewed by Doctor when possible. When completely settled, 50% of previous dose and then 20% increments No treatment and review by Doctor Page 6 of 24

7 5. Usual course: treatments. Maximum number of treatments per course: 30. Maximum dose per treatment: 15 J/cm 2. Lifetime limit of 200 treatments. 6. If develop small areas of erythema: repeat previous dose and apply high factor sunscreen to affected area for one treatment. 7. If develop facial erythema or unacceptable facial pigmentation, a face shield or sunscreen should be used for each treatment. 8. If develop pruritus: encourage use of emollients and antihistamines. 9. If develop Polymorphic Light Eruption (PLE): treat with emollients and very potent topical steroids (eg. Dermovate) immediately after treatment. Postpone treatment if troublesome and reduce to 20 % increments. 10. Cancellation/ missed treatments: see missed treatment protocol. 11. Discharge: see discharge protocol. 13. Documentation: Copies of Treatment summary to be sent to responsible consultant and entered on EPR. 14. Eczema PUVA Initiating dose: 0.5J/cm PUVA increments: 40%. If E1 erythema develops, change to 20% increment End of phototherapy course taper treatment, with 20% reduction in dose for each treatment: -use last dose at 1/week for 6 weeks, -then discharge. 15. Vitiligo PUVA Initiating dose dose: 0.5J/cm PUVA increment: 0.5J/cm 2 until vitiligo is just pink, then maintain or increase by 0.1J/cm Minimum 3 monthly treatment. If no response discontinue Follow up by doctor every 20 treatments Maximum 12 months treatment Clinical photographs at the start of treatment and every three months. 16. Polymorphic Light Eruption (or other photosensitivity disorder) PUVA Initiating dose: 0.5J/cm 2 Page 7 of 24

8 16.2. PUVA increment: 40% of previous dose over 4 weeks /week for 4 weeks, i.e. 8 treatments in total TREATMENT NUMBER SYSTEMIC PUVA J/cm If develop PLE during treatment, -If mild, continue with treatment in combination with emollients and topical steroids (eg. Dermovate ointment for body, eumovate for face). -If severe, treat with emollients and topical steroids AND stop treatment until rash clears, then recommence at a lower dose. -Very severe flares may require oral prednisolone discuss with doctor /book into clinic Encourage patients to keep their sun tolerance topped-up by regular sun exposure throughout spring/summer. 17. Mycosis Fungoides Systemic PUVA for plaque stage MF (UVB suitable for patch stage MF) Initiating dose and increments as for standard protocol Continue until skin clear no limit to number of treatments each course or lifetime If maintenance phototherapy is required once skin is clear, consider 1/week or less. Review every 20 maintenance treatments. 18. Palmoplantar Pustulosis Systemic PUVA with or without retinoids If initiating Acitretin midway during phototherapy, hold UV dose for three sessions before increasing dose as per regime. Consider Acitretin dose of mg daily Initial irradiation dose: as per standard protocol Maximum no. of treatments: 30 for hands, 40 for feet. 19. Palmoplantar Eczema/ Psoriasis Consider hand and foot oral PUVA for hyperkeratotic conditions Maximum no. of treatments: 30 for hands, 40 for feet. Page 8 of 24

9 TREATMENT PROTOCOL No. 3: Hand and foot PUVA soaks ml of 8-MOP 1.2% lotion in 2L water (concentration of 3mg/L). 2. Soak for 15 minutes, with a delay of 30 minutes before UVA exposure. 3. For gel (0.005% 8-MOP solution in aqueous gel), apply a thin layer over the affected areas, taking care to avoid applying to surrounding unaffected skin. Then wait for a further 15 minutes prior to treatment. 4. Initial irradiation dose: Skin phototype SOAKS GEL I (Always burn, never tan) II (Usually burn, sometimes tan) III (Usually tan, sometimes burn) IV (Never burn, always tan) V (Brown skin) VI (Black skin) Topical PUVA to be given twice weekly for most cases, with 3 days between treatments. 6. All patients to wear UV opaque goggles when having UV irradiation to their hands or feet. 7. Incremental regime and action to be taken: see also Dose to Time Conversion Table Grade Definition Action E0 No erythema and no report of erythema after last treatment E0+1 Patient reports erythema after last treatment but now resolved 40% increment; for 1/week treatment use 20% 40% increment but if previous E0+ then hold dose or 20% increment E1 (mild) Barely perceptible Repeat previous dose then consider asymptomatic erythema 20% increments E2 Well-defined erythema, Postpone one treatment if not (moderate) possibly causing slight completely settled; if settled, repeat manageable discomfort previous dose and thereafter consider 20% increments E3 (severe) Well-defined No treatment and reviewed by symptomatic/painful Doctor when possible. When erythema completely settled, 50% of previous dose and then 20% increments E4 (very Painful erythema usually No treatment and review by Doctor Page 9 of 24

10 severe) with blistering 8. Usual course: 30 treatments. Maximum number of treatments per course: 40. Maximum dose per treatment: 10 J/cm 2. Lifetime limit of 200 treatments. 9. If develop small areas of erythema: repeat previous dose and apply high factor sunscreen to affected area for one treatment. 10. If develop erythema on dorsum of hands or feet due to reflection whilst canopy is off, cover dorsum of hands or feet with towels during treatment. 11. If develop pruritus: encourage use of emollients and antihistamines. 12. If develop Polymorphic Light Eruption (PLE): treat with emollients and very potent topical steroids (eg. Dermovate) immediately after treatment. Postpone treatment if troublesome and reduce to 20 % increments. 13. Cancellation/ missed treatments: see missed treatment protocol. 14. Discharge: see discharge protocol. 15. Documentation: Treatment summary to be entered on EPR and copies to be sent to responsible consultant. Page 10 of 24

11 TREATMENT PROTOCOL No. 4: Hand and foot oral PUVA 1. Initial irradiation dose: Skin phototype Start dose (J/cm 2 ) I (Always burn, never tan) 0.5 II (Usually burn, sometimes tan) 0.5 III (Usually tan, sometimes burn) 0.5 IV (Never burn, always tan) 0.5 V (Brown skin) 0.5 VI (Black skin) PUVA to be given twice weekly for most cases, with 3 days between treatments Methoxypsoralen (8-MOP) tablets are to be taken 2 hours before irradiation. The dose is calculated according to body surface area(m 2 ) (refer EPR / patient information/ body surface area). Dose of 8 MOP is 25 mg/m 2 ; dose of 5-MOP is 50 mg/m Incremental regime and action to be taken: (ref: Dose to Time Conversion Table) Grade Definition Action E0 No erythema and no report of erythema after last treatment E0+1 Patient reports erythema after last treatment but now resolved E1 (mild) E2 (moderate) E3 (severe) E4 (very severe) Barely perceptible asymptomatic erythema Well-defined erythema, possibly causing slight manageable discomfort Well-defined symptomatic/painful erythema Painful erythema usually with blistering 40% increment; for 1/week treatment use 20% 40% increment but if previous E0+ then hold dose or 20% increment Repeat previous dose then consider 20% increments Postpone one treatment if not completely settled; if settled, repeat previous dose and thereafter consider 20% increments No treatment and reviewed by Doctor when possible. When completely settled, 50% of previous dose and then 20% increments No treatment and review by Doctor Page 11 of 24

12 5. Usual course: 30 treatments. Maximum number of treatments per course: 40. Maximum dose per treatment: 10 J/cm 2. Lifetime limit of 200 treatments. 6. If develop small areas of erythema: repeat previous dose and apply high factor sunscreen to affected area for one treatment. 7. If develop pruritus: encourage use of emollients and antihistamines. 8. If develop Polymorphic Light Eruption (PLE): treat with emollients and very potent topical steroids (eg. Dermovate) immediately after treatment. Postpone treatment if troublesome and reduce to 20 % increments. 9. Cancellation/ missed treatments: see missed treatment protocol. 10. Discharge: see discharge protocol. 11. Documentation: Treatment summary to be entered on EPR and copies to be sent to responsible consultant. Page 12 of 24

13 TREATMENT PROTOCOL No. 5: Bath PUVA Phototherapy 1. 30ml of 8-MOP 1.2% lotion in 140L water (concentration of 2.6mg/L). 2. Bathe for 15 minutes, followed by immediate UVA exposure. 3. Initial irradiation dose: Skin phototype Start dose J/cm 2 I (Always burn, never tan) 0.2 II (Usually burn, sometimes tan) 0.3 III (Usually tan, sometimes burn) 0.4 IV (Never burn, always tan) 0.5 V (Brown skin) 0.5 VI (Black skin) Topical PUVA to be given twice weekly for most cases, with 3 days between treatments. 5. All patients to wear UV opaque goggles in the cabin. Face shield should also be worn unless significant lesions present on face. 6. Incremental regime and action to be taken: Grade Definition Action E0 No erythema and no report of erythema after last treatment E0+1 Patient reports erythema after last treatment but now resolved E1 (mild) E2 (moderate) E3 (severe) E4 (very severe) Barely perceptible asymptomatic erythema Well-defined erythema, possibly causing slight manageable discomfort Well-defined symptomatic/painful erythema Painful erythema usually with blistering 40% increment; for 1/week treatment use 20% 40% increment but if previous E0+ then hold dose or 20% increment Repeat previous dose then consider 20% increments Postpone one treatment if not completely settled; if settled, repeat previous dose and thereafter consider 20% increments No treatment and reviewed by Doctor when possible. When completely settled, 50% of previous dose and then 20% increments No treatment and review by Doctor Page 13 of 24

14 7. Usual course: 24 treatments. Maximum number of treatments per course: 30. Maximum dose per treatment: 10 J/cm 2. Lifetime limit of 200 treatments. 8. If develop small areas of erythema: repeat previous dose and apply high factor sunscreen to affected area for one treatment. 9. If develop pruritus: encourage use of emollients and antihistamines. 10. If develop Polymorphic Light Eruption (PLE): treat with emollients and very potent topical steroids (eg. Dermovate) immediately after treatment. Postpone treatment if troublesome and reduce to 20 % increments. 11. Cancellation/ missed treatments: see missed treatment protocol. 12. Discharge: see discharge protocol. 13. Documentation: Treatment summary to be entered on EPR and copies to be sent to responsible consultant. Page 14 of 24

15 TREATMENT PROTOCOL No. 6: Missed treatments for UVB, PUVA, hand and foot PUVA Ensure treatments have not been cancelled or missed due to erythema, if so follow appropriate protocol incremental regime. Missed 1 treatment Missed 2 treatments Missed 3 treatments Missed 4-6 treatments Missed >6 treatments UVB: Continue with previous increments. PUVA: Repeat previous dose. Repeat previous dose. Give dose before previous dose. Give 50% of previous dose. Refer back to consultant. Missed >3 weeks due to holiday or sickness Consult starting dose. Page 15 of 24

16 TREATMENT PROTOCOL No. 7: ACCIDENTAL UV OVERDOSE PROTOCOL 1. General points 1.1. Contact patient immediately and explain Make all efforts for patient to re-attend the phototherapy unit immediately for assessment and treatment. Prompt action will minimise UV damage Phototherapy Consultant, on call registrar, and GP to be informed Where a large error has occurred ( eg.>50% UVB dose, or >75% UVA dose), consider hospital admission for overnight observation and treatment If patient can be treated at home, frequent contact should be maintained Accurate documentation is vital; ensure all discussions are documented. All details to be entered in phototherapy notes and a copy sent for filing in main hospital notes; 1.7. Complete Trust incident form UVB-induced burns reach maximum intensity at hours, and fade thereafter. UVA-induced burns reach maximum intensity at 2-3 days for oral PUVA, or 3-5 days for bath PUVA. 2. Specific Treatment (give hospital prescription) 2.1. Oral Prednisolone to be given: 40 mg stat, followed by 30 mg /day for five days. 2.2 Topical treatment Dermovate ointment B.D. An emollient QID 2.3 Prescribe analgesics. 3. Follow-up 3.1. Offer daily dressings / nursing assessment to patient Review by medical staff within three days. Page 16 of 24

17 TREATMENT PROTOCOL No. 8: PROTOCOL for MANAGEMENT OF MINOR ADVERSE EVENTS 1. Acute adverse effects of PUVA 1.1. Severe burns - see Protocol Mild/localized burning emollients, Dermovate ointment, apply sunscreens to affected area 1.3. Erythema grade level of erythema and manage accordingly 1.4. PUVA itch uncommon, usually chest and arms. Emollients and antihistamines to tide patients over the first couple of week of PUVA. Occasionally this may be painful ; PUVA-pain consider changing to 5 MOP or bath PUVA PUVA blisters this is usually a phototoxic reaction, involving hands and feet. Consider concomitant photosensitizing drugs (eg. NSAID, thiazides, diuretics, tetracyclines, Neotigason) Tanning people with skin type IV and V may not consider tanning to be desirable. Patients with vitiligo may find tanning of normal skin worsening the overall appearance Provocation of PLE Prophylactic application of Dermovate ointment after each treatment session Reaction of Cold Sores If susceptible to cold sores, apply lip sunscreen or visor throughout duration of treatment. If develop cold sores early application of acyclovir cream five times a day Facial seborrhoeic dermatitis - affects about 5% of patients and is not very responsive to topical corticosteroids Other side effects photo-onycholysis, nail pigmentation facial hair growth in women, scalp hair growth in men curling of previous straight hair folliculitis and milia pseudoporphyria lichenoid eruption 2. Acute adverse events of UVB 2.1. Severe burns see protocol Transient erythema common; starts a few minutes after treatment and persist for up to 8 hours. It clears completely. Next erythemal assessment prior to the next dose of UVB should not be affected i.e. E0+ reaction Itch usually during first 2 weeks of treatment. Emollients and antihistamines Cold sores susceptibility to this should be prevented with lip sunscreen or visor. Treat with topical or oral acyclovir Blistering occurs at the margins of psoriasis plaques, especially on plaques around the mid and lower abdomen and buttocks. Page 17 of 24

18 PROTOCOL No. 9: MED Tester protocol MED (Minimum Erythema Dose) testing should be carried out on all patients prior to a course of narrowband UVB (TL01) phototherapy, except for vitiligo patients or where the patient's skin condition or other circumstances makes testing impractical. 1. Confirm that the patient will be able to return for evaluation of their skin response 24 hours (+/- 3 hours) after the test exposure. 2. Indentify a suitable skin area to which the MED tester can be applied. The area should have limited normal sun exposure, such as the inner surface of the forearm, and be clear of skin rashes or other skin surface changes that might complicate the assessment of the MED test. Ensure that the full area of the face of the MED tester will lie in contact with the patient's skin without undue pressure. 3. Select the test exposure time to be used on depending on the assessment of the patient's skin type. A shorter exposure time is used for Skin Types I and II, and a longer time for Skin Type III and above. 4. Prepare the MED tester and give the test exposure according to the local operating instructions. 5. Immediately the test exposure ends, mark the patient's skin beside the test area to indicate the orientation of the test area. Use a waterproof marker. Avoid marks within the actual test area. 6. In the patient's record, note the exposure time used. 7. After use, clean the MED tester with SaniCloth Detergent Wipes. 8. When the patient returns for the 24 hour response reading, examine the test area in a good light and decide which of the 10 individual test patches is just showing an erythema response. 9. From the comparison table for MEDs and phototherapy start doses, read off the MED for the appropriate test patch. Note the MED in the patient's record. 10. Also read off the corresponding phototherapy start dose and note this in the patient's record. Start doses are approximately 70% of the MED. 11. If the MED test result is unclear, e.g. all test patches with higher doses than the apparent MED patch do not also show erythema, use the standard starting doses based on skin type and skin disease. 12. Once the start dose has been determined, commence phototherapy treatment that same day. Page 18 of 24

19 PROTOCOL No. 10: Discharge protocol Treatment usually continues until the patient is clear, condition is no longer improving, has 4 treatments at MRA (minimal residual activity) or is stopped on medical advice. A phototherapy summary is sent to the referring clinician on completion of treatment. The following is a guide to follow-up care: 1. Patients completing treatment having incurred no problems discharge to referring clinician. 2. Patients who have failed to attend discharge to referring clinician. If patient has had mitigating circumstances, consider discussing with referring clinician. 3. Patients who are known to flare quickly when treatment is completed should be advised to contact the referring clinician if they develop a flare up or have concerns. 4. Patients attending for desensitisation who may require repeated treatment should be reviewed early the following year by the phototherapy clinic as appropriate. Page 19 of 24

20 PROTOCOL No. 11: Psoracomb (UVB-TL01) protocol 1. Determine the MED (Minimal Erythemal Dose), on mid-upper back, with readings at 24 hours. 2. Initial irradiation dose = 50% of MED. If the patient s back is too extensively involved to perform the MED, the starting dose should be according to the clinician s instructions. 3. Each patient will undergo a 2-day training programme which includes 1 supervised treatment using the Psoracomb. The training programme will be extended if the Psoracomb user does not demonstrate an understanding of the treatment guidelines protocol and/or competence in administering treatment. 4. The training programme will be repeated for further treatment courses. 5. Treatment will be administered on alternate days, commencing on 20% increments reducing to 10% increments following erythema. 6. Treatment will be documented each time, including missed treatments and any adverse effects. 7. ADVERSE EFFECTS a) Grade 1 erythema (mild) - barely perceptible and resolves within 48 hours. Repeat previous dose and reduce to 10% increments. b) Grade 2 erythema (moderate) - well defined erythema causing slight manageable discomfort. Postpone one treatment if not completely settled. If settled, repeat previous dose on next treatment day. Reduce to10% increments thereafter. c) Grade 3 erythema (severe) - well defined symptomatic/painful erythema. No treatment and review by clinician. d) Grade 4 erythema (very severe) - painful erythema, usually with bullae. No treatment and review by clinician. e) Phototherapy for the scalp - erythema and oedema may not always be seen because of the patient s hair. They may complain of heat and skin tightness instead. f) If the patient develops itch, encourage use of emollients. Patient to be reviewed by clinician if itch persists. 8. MISSED TREATMENTS If patient cancels or misses: 1 or 2 treatments - repeat previous dose. 3 treatments - administer penultimate dose. 4 or 5 treatments - administer 60% of the last treatment dose. Page 20 of 24

21 2 or 3 weeks - administer 50% of the last treatment dose If more than 3 weeks of treatment is missed, the patient must be reviewed by a clinician, otherwise they will be discharged to their GP or given a review appointment for Dermatology Clinic. Page 21 of 24

22 Protocol 12: MPD protocol for PUVA 1. MPD testing should be carried out on all patients prior to a course of PUVA photochemotherapy, except where the patient's skin condition or other circumstances makes testing impractical. 2. Confirm that the patient will be able to return for evaluation of their skin response 96 hours (+/- half-day) after the test exposure. 3. The patient should be instructed to take 8-MOP or 5-MOP tablets two hours before attending for MPD testing. 4. The method uses the Waldmann UV200AL canopy of the hand treatment unit so as to test with the correct PUVA spectrum. A singleuse disposable mask is used to give a series of different test doses all within a single exposure. 5. Identify a suitable skin area for the MPD test. The area should have limited normal sun exposure, such as the inner surface of the forearm, and be clear of skin rashes or other skin surface changes that might complicate the assessment of the MPD test. Ensure that the MPD test mask can be taped down so as to lie in even contact with the patient's skin. 6. Identify the test dose to be used on depending on the assessment of the patient's skin type. A shorter exposure time is used for Skin Types I and II, and a longer time for Skin Type III and above. 7. Warm-up the hand-unit UV200AL canopy with an exposure of about 5 minutes, e.g. set a dose of 2.00 J/cm2. Use UV shielding so that you can make other preparations during the warm-up. 8. Tape an MPD mask over the patient's skin area to be used. Tape additional UV protection, e.g. disposable drapes, around the edges of the mask to overlap the main printed area, but keep clear of the test circles. 9. Once the warm-up has finished, position the patient at the UV200AL unit with the test area directly facing the centre of the unit. 10. Ensure that all other areas of the patient's skin and their eyes will be protected from UV by drapes or other suitable protection. 11. Set the required test dose on the UV200AL. 12. Start the exposure. Supervise the patient as necessary to ensure that the test skin area stays in the correct position, and that UV protection remains effective 13. Prepare for the test and give the test exposure according to the technical procedure. 14. Immediately the test exposure ends, remove the mask and mark the patient's skin beside the test area to indicate the orientation of the test doses. Use a waterproof marker. Avoid marks within the actual test area. 15. In the patient's record, note the details of the test. 16. Dispose of the test mask and other single-use materials. 17. When the patient returns for the 96 hour response reading, examine the test area in a good light and decide which of the 10 individual test patches is just showing an erythema response. 18. From the comparison table for MPDs and phototherapy start doses, read off the MPD for the appropriate test patch. Note the MPD in the patient's record. Page 22 of 24

23 19. Also read off the corresponding phototherapy start dose and note this in the patient's record. Start doses are approximately 50% of the MPD. 20. If the MPD test result is unclear, e.g. all test patches with higher doses than the apparent MPD patch do not also show erythema, use the standard starting doses based on skin type and skin disease. 21. Once the start dose has been determined, commence phototherapy treatment that same day. Page 23 of 24

24 Standards (section number should follow on from the preceding section) Minimum service provision standards using the Phototherapy Review toolkit, as well as recommended Phototherapy Guidelines, as suggested by the British Association of Dermatologists can be viewed here: Explanation of terms Terms as described in document References and Supporting Documents For recommended phototherapy guidelines, see British Association Dermatologists website/phototherapy/phototherapy Service Provision in the UK Roles and responsibilities Lead Clinician: Dr Tsui Ling Lead Nurse: Sister Melanie Casey Medical Physicist: Dr Donald Allan Page 24 of 24