A review of home phototherapy for psoriasis
Published Web Location
https://doi.org/10.5070/D39r12n60xMain Content
A review of home phototherapy for psoriasis
Bridgit V Nolan1, Brad A Yentzer MD2, Steven R Feldman MD PhD2
Dermatology Online Journal 16 (2): 1
1. SUNY Upstate Medical University, Syracuse, New York2. Center for Dermatology Research, Department of Dermatology; Wake Forest University School of Medicine; Winston-Salem, North Carolina. sfeldman@wfubmc.edu
Abstract
Background: Phototherapy is a mainstay in the treatment of psoriasis and other photoresponsive dermatoses and home phototherapy has broadened therapeutic options. Purpose: To describe the history of home phototherapy, the technological advances in the safety and efficacy of the equipment available, and the associated issues of cost, convenience, adherence, and quality of life. Methods: We conducted a literature review of home phototherapy, broad-band UVB, narrow-band UVB, and PUVA phototherapy using PUBMED. A Google search of home phototherapy equipment and technology was also undertaken. Results: Technological advances in home phototherapy equipment have allowed for more treatment options and improvements in safety and efficacy. One randomized, controlled trial found results comparable to office-based phototherapy. Home phototherapy is convenient, cost-effective, and associated with better quality of life compared to outpatient phototherapy treatment. One trial found that adherence to home phototherapy regimens was better than to oral retinoids. Conclusions: Home phototherapy is a well-tolerated, efficacious, economical and patient friendly therapeutic option. Advantages of home phototherapy include improved quality of life, greater convenience, lower cost, and less time lost from work and social activities. Dermatologists should strongly consider home phototherapy as a first-line treatment option for appropriately selected psoriasis patients.
INTRODUCTION
Phototherapy has advanced much since the time of the ancient Egyptians when exposure to natural sunlight was used as a form of medical treatment for a variety of skin conditions. Self-treatment with UVA in the form of commercial tanning booths is widespread and many patients use this type of phototherapy without medical guidance. Fifty percent of patients with psoriasis have self-treated with sunbeds [1]. Technological innovations involving the development and improvement of ultraviolet-emitting devices designed for home phototherapy has widened the possibilities for home phototherapy of psoriasis and other photosensitive dermatoses, including mycosis fungoides, hand eczema, solar urticaria, and vitiligo [2].
Home phototherapy equipment first became commercially available in the early 1980s. Since its introduction, home phototherapy has been growing in use and is popular with many psoriasis patients [3]. An overwhelming majority (96%) of patients undergoing home phototherapy thought it was effective, as well as less costly and more convenient than the standard outpatient schedule. Not surprisingly, patient satisfaction with home phototherapy is very high [4]. Home phototherapy has evolved and improved over time. The purpose of this review is to describe the evolution of home phototherapy and to elucidate its role in the treatment of chronic inflammatory skin diseases.
METHODS
A review of the literature on home phototherapy, broad-band UVB (BB-UVB), narrow-band UVB (NB-UVB), and psoralen plus UVA (PUVA) phototherapy was conducted using PUBMED. The following search terms were used: phototherapy, home phototherapy, and psoriasis phototherapy. The efficacy, safety, and adverse effects of the various forms of phototherapy were investigated. Associated issues of convenience, cost, adherence, and quality of life were also assessed. A Google search for home phototherapy equipment and technology was undertaken. Emphasis was placed on technological evolution in the safety, efficacy, and personalization of the various units available.
RESULTS
Evidence supporting their utilization
As a first step to delineating the efficacy of home delivery of UV as a treatment, we describe the evidence for the efficacy of ultraviolet phototherapy in general. In the subsequent section, we discuss the research supporting the effectiveness of home phototherapy in the treatment of photoresponsive dermatoses.
Broad-band (BB) UVB phototherapy
Phototherapy with UVB spectrum light (290-320 nm) has been used to treat psoriasis for at least the past seventy years [5]. Immunosuppressive effects of phototherapy are likely a major component behind its efficacy. The proposed mechanism of action involves induction of apoptosis in both T lymphocytes and keratinocytes, leading to decreased inflammation and epidermal hyperplasia [6]. Exposure to UVB, either as a sole intervention or in combination with emollients or tar preparation, is an effective therapy in the treatment of psoriasis. UVB is effective alone, as psoriatic lesions improve in response to treatment with erythemogenic doses of UVB without the concurrent use of topical agents [7]. Successful clearance of psoriasis using UVB, with or without petrolatum, typically occurs within 6 weeks of treatment [8, 9, 10, 11, 12]. Weekly regimens range from 3 to 5 exposures per week, with an average of 25 doses to achieve clearance (n=30). Prolonged remission can be maintained with UVB treatments once every 1 to 5 weeks [11].
Narrow-band (NB) UVB phototherapy
Narrow-band (NB) UVB phototherapy is emitted by Philips TL01 lamps and consists of a subset of the UVB spectrum, with a peak at 311 nm. The development of NB-UVB in the 1980s has resulted in the ability to select the wavelength at which optimal response is achieved while minimizing the erythemogenic response to non-therapeutic wavelengths. Parrish and Jaenicke (1981) conducted a study to determine the optimal ultraviolet spectrum for use in phototherapy for psoriasis and demonstrated that the peak action spectrum for clinical efficacy is between 308 and 312 nm [13]. These findings form the basis for selective UV phototherapy. Maximal erythemogenic response occurs around 297 nm, which is absent in the newer NB-UVB light emitting devices. NB-UVB has a significant therapeutic effect in the treatment of psoriasis, eczematous conditions, pruritus, cutaneous T-cell lymphoma, and vitiligo [14, 15, 16, 17].
Narrow-band UVB phototherapy has a more profound efficacy compared to conventional BB-UVB, achieving faster and more complete clinical response of psoriatic plaques [18]. Coven et al. (1997) assessed this efficacy by comparing NB-UVB to BB-UVB, both with and without tar, in the treatment of patients with moderate-to-severe psoriasis. Their results confirmed that NB-UVB is superior, with clinical resolution in 86 percent of sites treated with NB-UVB versus 73 percent treated with BB-UVB and histopathological resolution in 88 percent of sites treated with NB-UVB and 59 percent of sites treated with BB-UVB [19]. Additionally, clinical resolution occurred more rapidly using NB-UVB, generally within two to three weeks of treatment [19]. These results were reproduced by a subsequent study involving psoriasis patients undergoing split-body treatment consisting of three sessions per week for six weeks using NB-UVB and conventional BB-UVB. Results demonstrated clinical clearing in 81.8 percent of patients on the NB-UVB side and 9.1 percent of patients on the BB-UVB side (n=11) [20]. Histopathological examination revealed reversal of epidermal hyperplasia in 75 percent of patients on the NB-UVB side compared with none on the BB-UVB side [20].
Comparisons using the split-body approach have been made to assess the relative efficacy of trimethylpsoralen bath PUVA and NB-UVB in patients with chronic plaque psoriasis [21, 22]. The decrease in Psoriasis Area and Severity Index (PASI) score was greater on the NB-UVB side compared with topical PUVA, and this difference occurred earlier during the course of treatment on the NB-UVB treated side. Additionally, NB-UVB treatment was associated with fewer side effects and better tolerability. These results suggest that NB-UVB is more effective, efficient, and better tolerated compared to topical PUVA in the treatment of chronic plaque psoriasis psoriasis [22]. Comparisons of PUVA with oral psoralen versus NB-UVB phototherapy demonstrate that PUVA is more effective and efficient in clearing and maintaining remission in patients with chronic plaque psoriasis (n=93). Clearance was achieved in 84 percent of patients treated with PUVA, after an average of 17 treatments compared to NB-UVB treatment, which resulted in clearance for 65 percent of patients after an average of 28.5 sessions (n=93). Remission at six months was 68 percent in the PUVA group versus 35 percent in the NB-UVB group. However, the side effects associated with PUVA were greater, with 49 percent reporting erythema in the PUVA group compared to only 22 percent in patients undergoing NB-UVB [23]. It should also be noted that this study used twice-weekly dosing with NB-UVB versus the standard 3-5 times per week of UVB phototherapy. Because PUVA is also associated with potential systemic side effects (erythema, pruritus, nausea, ocular damage, and increased risk of skin cancer) as well as death from accidental overexposure, it is generally not recommended as an option for home phototherapy [24, 25, 26].
Home Phototherapy
Over the years, there have been numerous studies to determine the efficacy of home phototherapy, including a simple evaluation of home phototherapy with and without the concurrent use of topical treatment, home phototherapy in addition to systemic therapy, and a pragmatic, randomized controlled trial comparing home versus outpatient phototherapy (Table 1). The efficacy of home phototherapy was demonstrated by complete remission of psoriatic lesions in 20 of 28 (71.4%) patients with long-standing, severe psoriasis after 45 exposures to high-dose BB-UVB home phototherapy as a sole therapeutic intervention [9]. Of note, the subjects underwent MED determination and were closely monitored for response to treatment with weekly visits. This arrangement constitutes more supervision than many home phototherapy regimens [3]. The need for adequate monitoring of response to treatment and incidences of adverse events is a major consideration in prescribing home phototherapy as a therapeutic intervention [27]. This consideration underscores the importance of using home phototherapy units equipped with prescription controlled timers to limit the number of treatments between office visits. Additionally, patients with extensive, recalcitrant psoriasis showed clearance of psoriatic lesions in 55 of 56 (98.2%) patients after 8 weeks of BB-UVB treatment in suberythrogenic dose with concurrent use of topical coal tar [28]. In patients with patch and early plaque stage mycosis fungoides, home phototherapy consisting of erythemogenic doses of UVB resulted in clinical and histopathological clearance and prolonged remission in 7 of 31 patients [29]. A comparison of the efficacy of high output UVB at home and at physician offices in patients with recalcitrant hand eczema demonstrated much improvement in 7 of 11 (63.6%) patients in the home group and 11 of 13 (84.6%) patients in the outpatient group [30]. Eighteen of 23 psoriasis patients demonstrated complete clearance with an additional 3 showing marked improvement with the use of NB-UVB [31]. NB-UVB was also shown to be effective in a variety of other photoresponsive dermatoses (Table 1) [31]. Home phototherapy in conjunction with oral acitretin for 12 weeks in patients with moderate-to-severe plaque psoriasis reduced PASI score by 22 percent and was clinically significant as demonstrated by an associated improvement in quality of life (as measured by DLQI) [32].
Home phototherapy had similar efficacy to outpatient phototherapy in a large, randomized, well-controlled trial (n=195). For patients undergoing home phototherapy, 82 percent and 70 percent reached Self-Administered Psoriasis Area and Severity Index (SAPASI) 50 and PASI 50, respectively, compared with 79 percent and 73 percent of the patients receiving outpatient treatment [33]. Additionally, the median SAPASI and PASI scores for patients receiving home phototherapy decreased by 82 percent and 74 percent, respectively, compared with 79 percent and 70 percent decreases in the outpatient group. The overall treatment effect, as assessed by the mean reduction in PSAI and SAPASI, and the increase in quality of life was significant and similar between the two groups [33]. As used in this study, home phototherapy was similar in efficacy to standard outpatient phototherapy.
Safety of home phototherapy devices
Adverse effects associated with phototherapy include both acute adverse effects and cumulative, dose-related effects that occur with prolonged use. Early adverse effects associated with BB- and NB-UVB phototherapy are typically limited to erythema and drying of the skin, with maximal erythema occurring between 8 and 24 hours following exposure [34]. Blistering represents a severe acute adverse event more commonly associated with exposure to BB-UVB phototherapy compared to NB-UVB, due to the lower erythemogenicity of NB-UVB. Concerns about the possible increased risk of acute adverse events in the home setting has raised questions about the appropriateness and safety of home phototherapy. Side effects of home phototherapy are common with 44 percent of patients reporting adverse effects, but the reported side effects are mild and include erythema (36%), blisters (1%), pruritus (8%), and dryness (1%) [4]. In a comparison to home versus outpatient phototherapy, there was mild erythema in 87 percent of subjects, burning sensation in 56 percent, severe erythema in 36 percent, and blistering in 6 percent, with no difference in incidence of acute adverse events between the two groups [33]. Thus, acute adverse effects appear to be mild and well-tolerated, with severe reactions occurring in low incidence. Late adverse effects result from the cumulative UVB dose, which leads to aesthetic changes, including premature aging (photoaging), wrinkling, and leathery appearance, increased fragility of the skin, and increased risk of photocarginogenesis [33]. Such late adverse effects correlate directly with the total cumulative dose and the incidence of acute adverse events [35, 36, 37]. Data investigating the carcinogenetic risk associated with exposure to BB- versus NB-UVB do not demonstrate a significant difference. Because photocarginogenesis is directly related to the cumulative dose of UV light and to the incidence of acute adverse events, the presumed long-term risk associated with home phototherapy may be similar to that associated with outpatient treatment. Whereas there are good data demonstrating the long-term safety of physician-administered phototherapy, no such data are available for home treatment. However, the existing data demonstrates no differences in acute adverse events or total cumulative ultraviolet dose and there are no data suggesting that home phototherapy is less safe than standard outpatient treatment [33].
Improved technology has allowed for the evolution of safer home phototherapy devices. Innovative safety features in newer units include a key-locked ON/OFF switch to prevent unauthorized use, a built-in controlled prescription timer (CPT), and a failsafe feature that disables the unit in the event of malfunction [38-45]. The controlled prescription timer (CPT) ensures that the equipment can only be used for a certain number of treatments as prescribed by the doctor between office visits. Such innovations make phototherapy safer and more appropriate for home use by allowing greater monitoring for appropriate response to treatment and for incidence of adverse events. Additionally, these features decrease the possibility of unauthorized use or inappropriate use and thus reduce physician and patient worry about potential side-effects, lack of follow up, or abuse [39].
Personalizing Home Phototherapy
An array of units of different sizes and designed for different purposes has been developed and allows for treatment of many different types of diseases (anatomic locations and distribution), ranging from full-body, to scalp, to hand and foot treatment (Table 2). Smaller, specialized units, such as handheld devices, allow for targeting of specific body areas and eliminate exposure of unaffected skin to ultraviolet light. The ability to perform such localized treatment may be more efficacious in treating certain diseases, particularly hand and foot diseases that require more intense regional treatment to penetrate the thick stratum corneum. For patients with more diffuse or total-body disease, the addition of reflecting side panels and wings increases the dispersion of ultraviolet rays, thus allowing a greater area to be well-treated in a uniform manner and in a lesser amount of time. Maximization of lamp output facilitates a shorter and more effective treatment session. A list of home phototherapy unit suppliers can be found on the National Psoriasis Foundation's website [40].
Practical use considerations
Prior to the initiation of a home phototherapy regimen, patients should undergo examination by their dermatologist to determine skin type and to establish diagnosis [46]. Additionally, a previous therapeutic response to outpatient phototherapy should be documented. The patient should be thoroughly educated as to practical use issues and goals of phototherapy as well as the anticipated response to and possible side-effects of treatment. The goal of therapy is to achieve clearing of psoriatic lesions within a period of several weeks without significant reddening/burning of the skin. The patient should be taught to differentiate between therapeutic response to treatment and adverse events, specifically reddening/burning versus painless pinkness of the skin. Additionally, patients should be educated as to proper and safe use of phototherapy equipment, including protection of eyes with UV goggles and covering of the genitals (for men) and nipples (for women). Patients should be informed of the importance of appropriate and consistent distancing from phototherapy equipment (1 foot is most desirable), which may be best achieved by using tape or other markings to indicate the desired distance. Finally, the importance of maintaining regular follow-up appointments, which are required to monitor response to phototherapy and to adjust dose appropriately, must be emphasized and understood by the patient.
Protocols for home phototherapy
A variety of protocols for home phototherapy have been developed and are tailored to fit different diseases, skin types, and minimal erythema dose (MED) [46]. A standard protocol for NB-UVB in the treatment of psoriasis consists of three sessions per week (treatment sessions every other day is most effective) for a duration of three months, with initial treatment time determined by skin type or MED and dose escalation depending on the patient's response to treatment and the physician/clinic preferences. For NB-UVB phototherapy, initial treatment time/dose may be based on the patient's skin type or MED. For MED-based NB-UVB regimens, 0.7 MED is the most frequently used initial dose, with recommended range of 0.5 - 1.0 MED [47, 48, 49, 50, 51, 52]. In terms of increase in treatment time, the magnitude of dose increase depends on the patient and the provider. There are a variety of strategies to increase treatment time: some increase the dose in increments of 10-20 percent with each treatment session; others use larger dose increments (15-20%) early in the course of treatment followed by smaller increments (10%) later on [44, 53]. Whereas MED-based therapy is thought to be safest, treatment time based on the patient's skin type is more convenient and as such is utilized by many practitioners [54]. For skin type-based regimens, the initial treatment time is based on the patient's Fitzpatrick Skin Type (Table 3 and Table 4) and subsequent increases in treatment time are based on skin type and response to the most recent treatment. If slight erythema or pinkness of the skin results from the most recent treatment, the patient should be instructed not to increase the treatment time. If reddening or sunburn occurs, patients should be instructed to stop treatment until reddening resolves and to resume treatment at one-half the previous exposure time. If no erythema or pinkness of the skin resulted from the most recent treatment, patients should be instructed to increase their treatment time based on skin type (Table 5). With body MED-based and skin type-based regiments, phototherapy sessions are continued until total remission is achieved or no further improvement can be attained [49].
Advantages of home phototherapy
The advantages of home phototherapy to both doctor and patient are numerous and include convenience, lower cost, better adherence to treatment, and improved quality of life [55]. In terms of treatment effectiveness, adherence is one of the most important factors in determining clinical outcomes. Patients' adherence to home phototherapy regimens is high and may be even better than to oral psoriasis treatment [32]. Furthermore, improved quality of life, which is attributable to a certain form of treatment, is likely to foster better adherence to that treatment.
Convenience
Repeated journeys to the hospital or outpatient offices for phototherapy pose an obvious inconvenience and expense. Geographic, work, and economic constraints compound the difficulty for patients to maintain an adequate treatment schedule. Treatment plans which are too complicated, costly, or time-consuming may increase the burden of chronic disease. Convenience factors played a major role in patients' decisions regarding mode of treatment and adherence to treatment. In a survey of patients undergoing home phototherapy, forty percent of users identified “time” as their reason for selecting home phototherapy and an additional seventeen percent chose it due to “difficulty with work schedule” [4]. Other reasons relating to convenience included “convenience of being at home” and “moving from the city” [4]. In another survey, 42 percent of patients undergoing outpatient phototherapy described this method as “inconvenient” and 75 percent indicated that home phototherapy would be helpful [31]. The importance of convenience factors and the relationship between convenience and adherence has been emphasized in the dermatology literature [56]. Additionally, technological advances in equipment design have made home phototherapy units more convenient. Home phototherapy units now operate on standard house electrical current. Many have convenience features, such as casters, which allow for easy moving; adjustable wheels that ease movement on any type of floor surface; and wings or doors, which can be closed or folded away for easy storage (Table 2).
Cost
The cost of long-term management of severe psoriasis has risen dramatically with the recent development of injectable immunomudulators. There is significant variability in cost and efficacy of different treatment options and patients may respond better to some treatments than others [55]. Cost, both direct and indirect (loss of work and from social and family activities), is an important consideration in optimizing treatment outcomes. In a payer-perspective cost model that compared the direct expenditures associated with the long-term management of psoriasis using various treatments, home UVB phototherapy was less costly than any other treatment for severe psoriasis (including methotrexate, PUVA, acitretin, and biologic agents) [55]. Additionally, a survey of patients using home phototherapy demonstrated that 25 percent of patients chose home phototherapy due to travel expenses associated with outpatient phototherapy [4]. Loss of earnings associated with missing time from work to attend outpatient phototherapy sessions was another factor contributing to patients' preference for home phototherapy [4]. These findings, in conjunction with the efficacy and safety profile of home UVB phototherapy, render it a cost-effective choice for long-term management of photoresponsive dermatoses [55].
Adherence
Poor adherence to treatment is ubiquitous in dermatology. With regards to home phototherapy, concerns arise about the possibility of over use, under use, and inappropriate use [39]. Proper patient education and the presence of newer safety features installed in home phototherapy units help ensure appropriate use of home units [3]. Few studies have addressed the issue of adherence to home phototherapy. One recent study of patients with moderate-to-severe psoriasis assessed adherence to oral acitretin and home UVB phototherapy. Patients were instructed to use home phototherapy three times per week, along with daily oral acitretin, for twelve weeks. Adherence to the home phototherapy regimen was good throughout the study, with patients using phototherapy between two and three times per week [57]. Adherence to the oral acitretin, however, decreased over the 12 week trial period. Side effects of the treatment did not appear to impact adherence [57]. Adherence to home ultraviolet phototherapy was better than oral acitretin. Selection of patients interested in participating in a home phototherapy trial could have contributed to this difference, however. Patients' perception of the effectiveness of a treatment can also influence adherence. Perception of the effectiveness of home phototherapy is very good, with 96 percent of patients reporting positive results [4]. Additionally, treatment satisfaction is greater with home phototherapy, as 43 percent of these patients reporting “excellent” treatment, compared with 23 percent of patients undergoing standard outpatient phototherapy [33].
Quality of life
Many patients with chronic dermatologic disease report decreased quality of life and adverse characteristics of treatment as major factors contributing to the impact of psoriasis. Home phototherapy and standard outpatient phototherapy are associated with significant and similar increases in quality of life. However, home phototherapy is associated with a significantly lower burden of treatment [33]. A greater sense of control, self-confidence, and well-being may be achieved with home phototherapy [58]. Home phototherapy, which eliminates the burden of travel, time lost from work, and interference with other family and social activities, is more convenient, less stressful, and poses fewer impediments to normal life [4]. Stress is thought to be a factor in psoriasis exacerbations. Thus, home phototherapy, which reduces patient stress levels in response to outpatient visits, may prove to have a beneficial effect in reducing the number and frequency of exacerbations in psoriasis patients.
Medico-legal issues and monitoring
As with any form of prescribed treatment, there are certain medico-legal issues that must be considered. Medico-legal issues are not a major obstacle in the use of home phototherapy regimens for a variety of reasons. These include: proper patient selection (limiting its use to patients with prior demonstrated therapeutic response to phototherapy and who can be relied on to maintain regular follow up), built-in control devices (such as the prescription controlled timers which limit number of sessions between office visits), and the history and documented record of the safety of home phototherapy compared to other alternatives (such as methotrexate, which has systemic toxicities). Adequate monitoring with close clinical follow up ensures that treatment is safe and effective. This also allows for the regimen to be adjusted in the event of suboptimal response to treatment or reported adverse events.
CONCLUSION
Home phototherapy is an effective means of treating chronic photoresponsive dermatoses. Efficacy, lower cost, convenience of use, and better quality of life all contribute to patient preference and better adherence. The development of narrow-band UVB and safety features for the various home units have helped to make this form of therapy more appropriate and less hazardous. The variety of sizes and options offered by the newer home phototherapy units allows better treatment of different areas and distributions of disease. Cost has become an even more important consideration in evaluating medical treatment options and home phototherapy is less costly than many alternatives. Home phototherapy has broadened therapeutic options, improved the quality of life for many patients, and should be considered as a primary treatment option for psoriasis treatment.
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