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Surgery and Cosmetics

Home Phototherapy for Psoriasis

Kathryn Anderson , Steven R. Feldman, MD, PhD

Wednesday, March 18, 2015

Psoriasis treatment has been revolutionized by the development of biologics - for years a hot topic in dermatology. While costly, the excitement for biologics has overshadowed long-standing, lower-cost treatment options. Phototherapy is still an effective treatment for psoriasis. However, office-based phototherapy is inconvenient and, in the USA at least, an office-based approach may also be more costly to the patient than taking a biologic treatment.

Phototherapy can also be administered at home. Indeed, when monitored closely, home narrow-band ultraviolet B (UVB) is as effective as office-based phototherapy treatments.1 Home phototherapy is also a very low-cost way to manage extensive psoriasis, although in the USA, the cost to the patient may still exceed that of a biologic (particularly because of the co-payment assistance programs offered by manufacturers of biologics).2,3 One concern with home phototherapy is that patients may be poorly adherent to the treatment. However, a well-designed study with electronic monitoring of home phototherapy found that adherence to home light treatments can be good, particularly in the short term.4 In addition, for patients with more severe extensive psoriasis, home UVB phototherapy can be combined with oral acitretin.

Home phototherapy is currently underprescribed. Many doctors may not know how to prescribe home phototherapy and many may not be trained in how it should be used.5 Here is advice on how to prescribe home phototherapy:

Choosing the right patient

Effective for patients with thin, extensive lesions.

May not be a good choice for:

  • Palm/sole psoriasis (UVB does not penetrate very deep into tissue)
  • Patients who drink heavy amounts of alcohol, as intoxication could lead to injury from phototherapy or from falls
  • People who travel frequently

Prescribing a device

Typically a 6-foot-tall narrow-band UVB device will be prescribed (see Figure 1). Information about phototherapy suppliers can be obtained at http://www.psoriasis.org/about-psoriasis/treatments/phototherapy/uvb/home-equipment or via an Internet search. Suppliers will provide detailed instructions on how to prescribe their devices. Many suppliers provide prescription pads that make it easy to check off key information (which device, what type of bulb, what skin type). A flat-panel unit or a flat panel with 'wings' is typically prescribed (complete wrap-around units take up more space and are more expensive).

Prescribing a device with a 'prescription-controlled timer' can prevent the device from being used forever without monitoring.

Recommending a dosage schedule

The recommended dosing schedule depends on the patient's sensitivity to UV and how they use the device (they should typically stand 6 inches/15 cm from the device). The manufacturer may recommend a schedule. Because of all the vagaries that impact the dose, it may be simplest to recommend starting very slowly (15-second initial treatment). A 5-15% increase in time with each subsequent treatment is recommended, with the percent increase dependent on patient skin type (patients with darker skin may require greater increases in treatment time). Treatments can be done as often as daily with broad-band UVB or every other day with narrow-band UVB.

Monitoring

Patients can be monitored at intervals for improvement and for safety. Annual follow up may be reasonable for patients who are well controlled and are using the device only intermittently as needed to maintain good control.

Our preference is to only prescribe home phototherapy devices with a prescription-controlled timer. This permits only a fixed number of treatments, assuring that monitoring can be done at intervals, without unlimited use of the machine.

Other hurdles

Obtaining coverage by health insurers may be difficult at times (because of the uncommon use of these devices, insurers may be unfamiliar with them). Phototherapy manufacturers may have staff that will help contact insurers. Sometimes, letting the insurer know how much they will be saving by not having the patient on a biologic may encourage better coverage of the home phototherapy device. In the USA, with its patchwork health insurance coverage, many phototherapy suppliers will also be willing to work with the patient to develop a payment plan, if necessary.

 

Phototherapy

Figure 1. A typical home phototherapy device (courtesy of National Biological Corporation).

When office-based and home phototherapy are not options, sun exposure or even a tanning bed may be other low-cost options suitable for some patients. As always, physicians need to use their good judgment when planning treatment.

References:

  1. Koek MB, Buskens E, van WH, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009;338:b1542.
  2. Staidle JP, Dabade TS, Feldman SR. A pharmacoeconomic analysis of severe psoriasis therapy: a review of treatment choices and cost efficiency. Expert Opin Pharmacother 2011;12:2041-54.
  3. Yentzer BA, Yelverton CB, Simpson GL, Simpson JF, Hwang W, Balkrishnan R, et al. Paradoxical effects of cost reduction measures in managed care systems for treatment of severe psoriasis. Dermatol Online J 2009;15:1.
  4. Yentzer BA, Yelverton CB, Pearce DJ, Camacho FT, Makhzoumi Z, Clark A, et al. Adherence to acitretin and home narrowband ultraviolet B phototherapy in patients with psoriasis. J Am Acad Dermatol 2008;59:577-81.
  5. Greist HM, Pearce DJ, Blauvelt M, Feldman SR. Resident education: effect of the sixth national psoriasis foundation chief residents' meeting. J Cutan Med Surg 2006;10:16-20.


 

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