Phototherapy for Psoriasis. Henry W. Lim, MD Chairman and C.S. Livingood Chair Department of Dermatology Henry Ford Hospital, Detroit, MI, USA
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1 Phototherapy for Psoriasis Henry W. Lim, MD Chairman and C.S. Livingood Chair Department of Dermatology Henry Ford Hospital, Detroit, MI, USA
2 Disclosure Investigator: Clinuvel Estée Lauder Ferndale Incyte
3 To be able to: Learning Objectives Review the application of ultravioletbased therapy for psoriasis Know the protocol Describe the side effects of UV therapy
4 Guidelines on Phototherapy Psoriasis AAD Psoriasis Guidelines: Menter A, et al. J Am Acad Dermatol. 2010;62:114. CTCL US Cutaneous Lymphoma Consortium: Olsen EA, et al. J Am Acad Dermatol. 2016; 74:27 Vitiligo Vitiligo Working Group: Mohammad TF, et al. J Am Acad Dermatol. 2017; 76:879
5 UV-based Therapy for Psoriasis NB-UVB Targeted phototherapy PUVA
6 UV-based Therapy for Psoriasis NB-UVB
7 NB-UVB for Psoriasis Before After 21 tx PUVA > NB-UVB > BB-UVB
8 NB-UVB: Protocol Ideally, MED should be done Mean MED: I III: mj/cm 2 IV VI: mj/cm 2 Start 70% MED, increase by 10-15% per treatment Maximum: 3 J/cm 2 to body; 1 J/cm 2 to face
9 Protocol: NB-UVB Skin type Initial UVB Dose (mj/cm 2 ) Dose Increase per Treatment Maximum Dose* (mj/cm 2 ) I % 3000 II % 3000 III % 3000 IV % 3000 V % 3000 VI % 3000 * 1000 mj/cm2 maximum dose for face
10 Protocol: NB-UVB Noticeable improvement should occur in treatments Once optimal improvement has been achieve, taper to twice weekly for 4 wks, and once weekly for 4 wks, then d/c Hold dose at once weekly regimen
11 Combination Therapy Topical corticosteroids Anthralin Calcipotriene ointment/cream Tazarotene gel Traditional systemics (methotrexate, cyclosporine, acitretin) Biologics
12 Combination Therapy Topical corticosteroids Anthralin Calcipotriene ointment/cream Tazarotene gel Traditional systemics (methotrexate, cyclosporine, acitretin) Biologics
13 Home Phototherapy (Anderson, KL, Feldman, SR. JAAD 2015 (May); 72:868. North Carolina) Basic model: $2500; 3-panel: $6000 Output stated in mw/cm 2 (measured 9 inches away) Conversion table provided Top row: output in mw/cm 2 Left hand column: dose in mj/cm 2 Exposure time (min/sec) can be easily read Convenient for pts
14 Home Phototherapy (Anderson, KL, Feldman, SR. JAAD 2015 (May); 72:868. North Carolina) Limitations: Insurance coverage Patient compliance Maintenance vs clearing
15 NB-UVB and Folate (Vit B9) (Zhang, M, Goyart, G, Lim, HW. J Am Acad Dermatol Nov; 77:958. Detroit) In vitro, photodegradation of folic acid occurs following exposure to nm radiation In vivo: UVA: No evidence of decrease of folate levels Sunlight: Decreased levels only in those taking folate supplement NB-UVB: mixed results (higher doses lower levels)
16 NB-UVB and Folate (Vit B9) (Zhang, M, Goyart, G, Lim, HW. J Am Acad Dermatol Nov; 77:958. Detroit) Folic acid deficiency has been associated with neural tube defects in fetus Complete closure of neural tube closure occurs 4 weeks after conception, before many women realize they are pregnant
17 NB-UVB and Folate (Vit B9) (Zhang, M, Goyart, G, Lim, HW. J Am Acad Dermatol Nov; 77:958. Detroit) Women planning or capable of pregnancy and receiving phototherapy: should get 0.8 mg/d of folic acid supplement (Folic acid = synthetic form of folate) Consistent with the current recommendations of the United States Preventive Services Task Force (JAMA Jan 2017; 317:183)
18 NB-UVB: Long Term Side Effects (Hearn, RMR Ferguson, J, Dawe, RS. BJD 10/08; 159:931. Dundee) 4665 pts; 55% w/ psoriasis 97% of pts: SPT I-III NB-UVB No increase in BCC, SCC, or melanoma Pts w/ NB-UVB + PUVA: slight increase in BCC
19 UV-based Therapy NB-UVB Targeted phototherapy
20 308-nm Xenon-Chloride Excimer Laser
21 308-nm Excimer Laser: Psoriasis (Feldman, SR, JAAD 6/2002; 46:900) MED. Starting dose: MED & physical characteristics of lesion (usually 3 MED) Twice weekly for 10 tx 72% (66/92): >75% clearing, 6.2 tx 50%: >90% clearing in 10 or less tx
22 Excimer Laser: Psoriasis After 1 tx
23 Targeted Phototherapy Noticeable improvement should occur by 6-10 treatments Discontinue after treatments, without tapering.
24 Targeted Phototherapy: Psoriasis Ideal for those with <10% BSA Residual resistant lesions following other forms of tx Hyperkeratotic lesions on palms and soles Scalp lesions
25 Targeted Phototherapy: Limitations Perilesional hyperpigmentation Problematic for face Travel time to phototherapy unit Insurance coverage/expense
26 UV-based Therapy for Psoriasis NB-UVB Targeted phototherapy PUVA
27 PUVA = 8 Methoxypsoralen + UVA
28 Pyrimidine-Psoralen Monoadducts
29 Pyrimidine-Psoralen Bifunctional Adducts
30 PUVA Protocol Oxsoralen Ultra (liquid formulation of 8-MOP) mg/kg; 1 hour prior to UVA (5-MOP: 1.2 mg/kg) Maximum: 70 mg Three times or twice per week
31 Protocol Skin Initial Dose Increments Max Type (J/cm 2 ) (J/cm 2 ) (J/cm 2 ) I II III IV V VI
32 Side Effects Acute: Nausea (psoralen) Phototoxicity (48 72 hrs)
33 UVA, UVB, PUVA-induced Skin Changes 0 h 2 h 5 h 24 h 48 h W. Gange (courtesy of N. Kollias) 72 h 10 d
34 Side Effects Acute: Nausea (psoralen) Phototoxicity (48 72 hrs) Pruritus Nail changes
35 Melanonychia Photoonycholysis
36 Chronic: Side Effects Lentigines
37 PUVA Lentigines
38 Side Effects Chronic: Lentigines Photoaging Photocarcinogenesis
39 PUVA and NMSC (Nijsten TEC, JID 8/03; 121:252. Boston) Prospective study: incidence of skin cancer in 1380 pts tx w/ PUVA First 15 yrs: no increase After 25 yrs: 200 tx: 7% of pts had SCC 400 tx: 50% had SCC 200 tx: 33% had BCC
40 PUVA and Melanoma (Stern, RS. J Am Acad Dermatol 2001; 44:755) 1380 Pts Pts developed 26 melanomas Melanoma pts: SPT I and II > 250 treatments Longest follow up (>15 yrs)
41 PUVA and Melanoma (Ling, TC, et al. Br J Dermatol 2016; 174: 24) European follow up study: NO increase in melanoma
42 PUVA and Pregnancy (Ling, TC, et al. Br J Dermatol 2016; 174: 24) Mutagenic, but not teratogenic in human PUVA should be avoided during pregnancy
43 UV-based Therapy for Psoriasis NB-UVB Targeted phototherapy PUVA
44 To be able to: Learning Objectives Review the application of ultravioletbased therapy for psoriasis Know the protocol Describe the side effects of UV therapy
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