In the JournalsPerspective

Joint guidelines explore best practices in NB-UVB therapy for psoriasis

Based on the available literature, the American Academy of Dermatology and the National Psoriasis Foundation published joint guidelines on ultraviolet light-based therapies for the treatment of psoriasis.

Here, Healio Dermatology summarizes the joint findings on the risks and benefits of narrowband ultraviolet light B (NB-UVB) treatment.

NB-UVB refers to wavelengths from 311 nm to 313 nm and is typically used to treat generalized plaque psoriasis, according to co-chair of the guidelines Craig A. Elmets, MD, from the University of Alabama, and colleagues.

The researchers recommended treatment two or three times a week and warned that a greater frequency results in minimal benefit and may expose a patient to a higher total dose of UVB radiation, leading to a greater risk for UV-induced erythema. Before treatment, a thin layer of emollient such as petrolatum should be applied to increase effectiveness and reduce erythema.

Based on comparative studies, psoralen plus ultraviolet A (PUVA) resulted in faster clearance with less treatment than NB-UVA, according to the researchers; however, oral PUVA has a higher rate of adverse effects.

“Although PUVA monotherapy was more effective than NB-UVB in many studies, superior short-term and long-term safety, simplicity and lower cost favor NB-UVB as the preferred treatment for plaque psoriasis,” they wrote.

If patients are unable to travel to a phototherapy center, home NB-UVB units can be considered.

“The burden of treatment was significantly lower, and patients were happier with their treatments when the UV light was delivered in the home phototherapy setting,” Elmets and colleagues wrote.

The data are mixed regarding the use of topical calcipotriol with NB-UVB.

“The apparent lack of an added effect of calcipotriol might be due to the fact that vitamin D analogues are degraded by exposure to UV radiation,” the researchers wrote.

Topical psoralens have also been studied in conjunction with NB-UVB, but researchers determined there is insufficient evidence to recommend the combination.

The use of methotrexate as a systemic adjunct to NB-UVB is not supported by the literature.

Oral retinoids have a beneficial effect with NB-UVB, decreasing the number of treatments and UVB dose.

Cyclosporine is often used in the treatment of psoriasis, but simultaneous use with NB-UVB is contraindicated due a higher risk for skin cancer.

The use of certain biologics is also supported as combination therapy with NB-UVB, and researchers recommended its use for cases in which monotherapy with either treatment is insufficient.

Ninety-five percent of patients who were treated with NB-UVB three times per week along with adalimumab 40 mg every other week achieved a 75% improvement in Psoriasis Area Severity Index score (PASI 75) at week 12, with 65% of patients maintaining PASI 75 at week 24, according to researchers.

Apremilast has been used with phototherapy, and the researchers supported this combination.

Concerns remain about the long-term risk for photocarcinogenesis with combined NB-UVB and PUVA therapy, so the researchers concluded that there is insufficient evidence to recommend this treatment.

As for risk management, the researchers recommend genital shielding in all patients undergoing phototherapy sessions to reduce the risk for genital skin cancer, as well as goggles for eye protection to reduce the risk for UVB-related ocular toxicity.

The risk for photocarcinogenesis is correlated with the number of treatments received.

“Because of the theoretical possibility of this risk, physicians should use caution in prescribing NB-UVB for patients with a history of melanoma, multiple nonmelanoma skin cancers, arsenic intake or exposure to ionizing radiation,” the researchers wrote.

NB-UVB is considered safe in pregnancy, although it may lead to a degradation of folate. Thus, women of childbearing potential should supplement with folate 0.8 mg daily. – by Abigail Sutton

 

Disclosures: Elmets reports he served as a consultant for Ferndale Laboratories; a consultant and advisory board member for Vertex Pharmaceuticals; a principal investigator for the California Association of Winegrape Growers; an investigator for Elorac, Idera Pharmaceuticals, Kyowa Hakko USA and Solgenix; a data safety monitoring board member for Astellas Pharma US and Leo; and a stockholder for Medgenics, Aevi Genomic Medicine and Immunogen. Please see the study for all other authors’ relevant financial disclosures.

Based on the available literature, the American Academy of Dermatology and the National Psoriasis Foundation published joint guidelines on ultraviolet light-based therapies for the treatment of psoriasis.

Here, Healio Dermatology summarizes the joint findings on the risks and benefits of narrowband ultraviolet light B (NB-UVB) treatment.

NB-UVB refers to wavelengths from 311 nm to 313 nm and is typically used to treat generalized plaque psoriasis, according to co-chair of the guidelines Craig A. Elmets, MD, from the University of Alabama, and colleagues.

The researchers recommended treatment two or three times a week and warned that a greater frequency results in minimal benefit and may expose a patient to a higher total dose of UVB radiation, leading to a greater risk for UV-induced erythema. Before treatment, a thin layer of emollient such as petrolatum should be applied to increase effectiveness and reduce erythema.

Based on comparative studies, psoralen plus ultraviolet A (PUVA) resulted in faster clearance with less treatment than NB-UVA, according to the researchers; however, oral PUVA has a higher rate of adverse effects.

“Although PUVA monotherapy was more effective than NB-UVB in many studies, superior short-term and long-term safety, simplicity and lower cost favor NB-UVB as the preferred treatment for plaque psoriasis,” they wrote.

If patients are unable to travel to a phototherapy center, home NB-UVB units can be considered.

“The burden of treatment was significantly lower, and patients were happier with their treatments when the UV light was delivered in the home phototherapy setting,” Elmets and colleagues wrote.

The data are mixed regarding the use of topical calcipotriol with NB-UVB.

“The apparent lack of an added effect of calcipotriol might be due to the fact that vitamin D analogues are degraded by exposure to UV radiation,” the researchers wrote.

Topical psoralens have also been studied in conjunction with NB-UVB, but researchers determined there is insufficient evidence to recommend the combination.

The use of methotrexate as a systemic adjunct to NB-UVB is not supported by the literature.

Oral retinoids have a beneficial effect with NB-UVB, decreasing the number of treatments and UVB dose.

Cyclosporine is often used in the treatment of psoriasis, but simultaneous use with NB-UVB is contraindicated due a higher risk for skin cancer.

The use of certain biologics is also supported as combination therapy with NB-UVB, and researchers recommended its use for cases in which monotherapy with either treatment is insufficient.

Ninety-five percent of patients who were treated with NB-UVB three times per week along with adalimumab 40 mg every other week achieved a 75% improvement in Psoriasis Area Severity Index score (PASI 75) at week 12, with 65% of patients maintaining PASI 75 at week 24, according to researchers.

Apremilast has been used with phototherapy, and the researchers supported this combination.

Concerns remain about the long-term risk for photocarcinogenesis with combined NB-UVB and PUVA therapy, so the researchers concluded that there is insufficient evidence to recommend this treatment.

As for risk management, the researchers recommend genital shielding in all patients undergoing phototherapy sessions to reduce the risk for genital skin cancer, as well as goggles for eye protection to reduce the risk for UVB-related ocular toxicity.

The risk for photocarcinogenesis is correlated with the number of treatments received.

“Because of the theoretical possibility of this risk, physicians should use caution in prescribing NB-UVB for patients with a history of melanoma, multiple nonmelanoma skin cancers, arsenic intake or exposure to ionizing radiation,” the researchers wrote.

NB-UVB is considered safe in pregnancy, although it may lead to a degradation of folate. Thus, women of childbearing potential should supplement with folate 0.8 mg daily. – by Abigail Sutton

 

Disclosures: Elmets reports he served as a consultant for Ferndale Laboratories; a consultant and advisory board member for Vertex Pharmaceuticals; a principal investigator for the California Association of Winegrape Growers; an investigator for Elorac, Idera Pharmaceuticals, Kyowa Hakko USA and Solgenix; a data safety monitoring board member for Astellas Pharma US and Leo; and a stockholder for Medgenics, Aevi Genomic Medicine and Immunogen. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Alan Menter

    Alan Menter

    Phototherapy for the treatment of psoriasis has advanced significantly since the early days, nearly 100 years ago, of Goeckerman therapy, i.e. the combination of crude coal tar plus broadband UVB (270-390 nm) in patient therapy.

    The introduction of narrowband UVB therapy (311-313 nm wavelength) has certainly made significant clinical improvement in psoriasis therapy, both in dermatologists’ clinical practice as well as for home phototherapy in psoriasis patients’ personal residences.  Patients with mild to moderate psoriasis unresponsive to traditional topical therapies, like corticosteroids traditionally develop a distinct improvement in their disease especially in areas like the trunk and limbs. Areas such as the scalp and body folds (flexures) which are frequently involved in psoriasis patients are not candidates for NBUVB phototherapy. 

    However, new, more targeted phototherapy instruments such as the excimer laser with a specific wavelength of 308 nm can certainly be used for recalcitrant psoriasis areas including the scalp, hands and feet plus elbows and knees.

    An interesting form of phototherapy called PUVA (psoralen UVA) introduced over 40 years ago has significantly higher response rates due to the interaction of the psoralen molecule, either orally or topically, prior to UVA phototherapy exposure. Two major side effects in PUVA therapy are 1) a significantly higher rate of skin cancers after over 100 plus therapies and 2) a significant degree of hyperpigmentation in fair-skin individuals.

    Finally, phototherapy is frequently combined with both topical agents, especially tar compounds (always used after the light treatment, never before) as well as systemic agents such as retinoids and biologics. Multiple studies have shown the advantages of these phototherapy combinations especially in patients not fully responsive to traditional topical, systemic and biologic therapies.

    • Alan Menter, MD
    • Chief of Dermatology, Baylor Scott & White
      Dallas, Texas

    Disclosures: Disclosures will be forthcoming.