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A clinical guideline regarding the use of phototherapy for the care and management of adult patients with psoriasis, developed by a collaborative effort between the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF), was published in the Journal of the American Academy of Dermatology. For the guideline, a committee consisting of members of the AAD and NPF discuss recommendations on the use of ultraviolet (UV) light-based therapies, photosensitizing agents, and new laser and light-emitting applications for the treatment of psoriasis.
UV Phototherapy Guideline Recommendations: Summary
Based on evidence published between 2008 and 2017, the ASD and NPF developed recommendations for both narrowband (NB-UVB) and broadband UV-B (BB-UVB) phototherapies.
NB-UVB Recommendations
The guideline recommends NB-UVB phototherapy monotherapy for adults with plaque psoriasis as an A-level recommendation. Additional A-level recommendations for NB-UVB include using a starting dose based on minimal erythema dose, using NB-UVB as a preferred alternative to psoralen plus ultraviolet A (PUVA) monotherapy, as well as BB-UVB monotherapy in adult patients with generalized plaque psoriasis, and using NB-UVB for all patients with guttate psoriasis.
Other recommendations from the AAD and NPF guideline include thrice-weekly dosing of NB-UVB for generalized plaque psoriasis (strength B), home NB-UVB as an alternative to in-office NB-UVB for appropriate patients with generalized plaque psoriasis (strength B), and concomitant topical therapy with vitamin D analogues, retinoids, and corticosteroids during NB-UVB treatment. Level-C recommendations were also provided in the guideline.
BB-UVB Recommendations
The guideline recommends BB-UVB as monotherapy in generalized plaque psoriasis cases when NB-UVB is unavailable (strength A). In addition, clinicians should consider BB-UVB as an inferior strategy to NB-UVB and oral PUVA monotherapy in terms of efficacy (strength A). Level B recommendations highlight the importance of genital shielding during BB-UVB to mitigate the risk for genital skin cancer, and the guideline also emphasizes caution when using BB-UVB in patients with a history of melanoma or multiple non-melanoma skin cancer.
Targeted UVB Therapy
Excimer laser (308 nm), excimer light (308 nm), and targeted NB-UVB light (311 to 313 nm) are targeted UVB treatments that the guideline recommends for localized psoriatic lesions (strength A). These targeted approaches spare unaffected skin and are associated with fewer risks than alternative treatments. The guideline suggests using targeted UVB two to three times per week. Adjustments to this schedule can be made based on the lesion’s physical characteristics.
Additional Recommendations
The guideline also discusses recommendations for grenz ray, climatotherapy, visible light, Goeckerman, pulsed dye laser, and intense pulsed light therapies in the management of psoriasis. Climatotherapy, or the act of moving a patient to another area of the world with a more suitable climate, was given a level B recommendation; a level C recommendation was applied to grenz ray, for which insufficient evidence exists to support its use in psoriasis management.
The guideline committee also emphasized the importance of discussing efficacy and safety data with patients so they can make an informed treatment decision. Quality of life assessment is also imperative prior to choosing a UV therapy for patients with psoriasis. “For the sake of convenience,” the guideline committee wrote, “less frequent phototherapy dosing (twice weekly) may be preferred by some patients despite the need to extend treatment duration to obtain the desired effect.”
Disclosure: Several of the study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Reference
Elmets CA, Lim HW, Stoff B, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with phototherapy [published online July 25, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.04.042
