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Current Considerations in the Treatment of Psoriasis With Phototherapy

Current Considerations in the Treatment of Psoriasis With Phototherapy

Where we are in the treatment of psoriasis now affords us the ability to select from multiple strategies to manage this chronic disease. Because of our options, we can really tailor the treatment to a patient’s individual circumstances and unique preferences. Though we have made significant advances with new therapeutics such as biologics and small molecule inhibitors, phototherapy remains an excellent option for many of our patients with psoriasis.

The literature over the years has shown phototherapy to be highly effective in many patient groups and sites on the body. The joint guideline on the use of phototherapy by the American Academy of Dermatology and the National Psoriasis Foundation goes into great detail about the efficacy and safety of each UV light-based modality, with evidence-based recommendations for monotherapy or in conjunction with topical and systemic psoriasis treatments.1 

However, in light of the COVID-19 pandemic and the necessity of social distancing, dermatologists have significantly reduced their operating hours or completely closed many phototherapy units. As certain areas begin to see a decrease in the number of new infections and deaths, in-office treatments may resume again with respect to local public health recommendations. To offer clinician-specific guidance, the dermatology expert committee of the Light Treatment Effectiveness (LITE) study2 offered recommendations for operating and/or reopening a phototherapy unit based on the consensus opinion.3 In addition, the phototherapy committee of the Academia Española de Dermatología y Venereología has also released recommendations for the management of phototherapy units during the pandemic.4

The main principle in these recommendations is the balancing act of the pros and cons, including for patient care but also for physician and staff safety and health. The risk of spreading SARs-CoV-2 infection in the dermatology office or shared phototherapy unit is quite low if physicians take care to use proper personal protective equipment (PPE) for themselves and staff with each patient to mitigate transmission risk.3 This could also mean delaying localized phototherapy with laser if this requires prolonged face-to-face treatment times or managing psoriasis through telemedicine so the patient does not have to travel into the appointment. Other recommendations3,4 to consider when administering in-office phototherapy include:

  • Screen all patients for symptoms and explain that symptoms may preclude patients from receiving treatment
  • The patient wears a mask at all times, unless a face dose is medically necessary, in which case the mask can be removed for when the patient is receiving a face dose
  • Allow only the patient at appointments, except in the cases of minors where one guardian (also screened and wearing a mask) should accompany the minor
  • Ensure that the patient has an individual set of goggles, whether transported to and from appointments by the patient or stored in a clearly labeled bag within the photomedicine unit
  • Disinfect all high-touch surfaces both in the phototherapy equipment and the changing area after each patient (though care should be taken to avoid damaging lamps)
  • Avoid fan use during a phototherapy application and use a segmented treatment strategy to avoid excessive heat build-up if necessary
  • Schedule patients at reduced intervals to allow maintenance of physical distancing in waiting areas

Role of Home Phototherapy
Home phototherapies are a reasonable option during the current pandemic and for any future public health crises. It not only reduces the burden of PPE use in offices but also the stress on patients who need to come in for treatment on a regular basis.

The LITE study2 (https://www.thelitestudy.com) is currently performing a large pragmatic trial of 1050 patients in 35 dermatology centers around the country to understand if home treatment is just as effective as being treated with phototherapy in the office. The ultimate goal of this work is to make patient care more patient-centered, as in-office administration is centered or “more convenient” for the physician. When the study is completed, we hope to show that home phototherapy works as well as it does in the office, with the hope that insurers will make this modality much more available to patients and that dermatologists will feel more confident in prescribing it based on the data. Home phototherapy can be relatively inexpensive compared with other therapies and highly patient-centered, allowing the patient to administer treatment without the extreme interruption to daily and weekly schedules.

Use of UV-C for Viricidal Purposes
Innovation in the face of medical supply shortages has led way to testing phototherapy units and UV germicidal irradiation as a possible disinfection method. Based on previous estimates regarding extrapolated viral inactivation data5-7 and studies on the decontamination potential of UV germicidal irradiation on filtering facepiece respirators,8-10 UV-C radiation may be an effective option for PPE disinfection.

Anecdotes of using UV-C radiation and in-office phototherapy devices have been shared during the pandemic. Dr ltefat Hamzavi, senior staff physician in the department of dermatology at Henry Ford Health System in Detroit, MI, described how his photomedicine clinic partnered with a manufacturer to develop a prototype to decontaminate N95 masks.11 At time of publication, Dr Hamzavi’s photomedicine clinic decontaminated more than 3000 masks from 18 hospitals across the country.

A note of concern, though, is that improper UV-C radiation can degrade materials and render N95 masks ineffective,12 so care should be taken to administer proper dosages to keep the integrity of the facemask intact.  

With that said, UV germicidal irradiation should not be used by laypeople to try to decontaminate masks or other personal items. The machines used in the treatment of psoriasis primarily utilize UV-B and are not providing effective levels of energy to disinfect solid objects. We should carefully explain to patients that the UV light used for psoriasis treatment will not be effective in cleaning personal items and surfaces in the home. We should also stress that misuse of UV radiation runs the risk of skin-damaging burns.


Dr Gelfand is professor of dermatology and of epidemiology; vice chair of clinical research and medical director, Clinical Studies Unit; director, Psoriasis and Phototherapy Treatment Center; and senior scholar, Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, PA.

Disclosure: Dr Gelfand is an investigator on the LITE study. He served as a consultant for Abcentra, BMS, Boehringer Ingelheim, Cara (DSMB), GSK, Lilly (DMC), Janssen Biologics, Novartis Corp, UCB (DSMB), Dr. Reddy’s Labs, Happify, Inc, Mindera Dx, Pfizer Inc, and Sun Pharma, receiving honoraria; and receives research grants (to the Trustees of the University of Pennsylvania) from AbbVie, Boehringer Ingelheim, Janssen, Novartis Corp, Celgene, Ortho Dermatologics, and Pfizer, Inc; and received payment for continuing medical education work related to psoriasis that was supported indirectly by AbbVie, Lilly, Ortho Dermatologics, Novartis, and other sponsors. Dr Gelfand is a co-patent holder of resiquimod for treatment of cutaneous T-cell lymphoma. He is a deputy editor for the Journal of Investigative Dermatology, receiving honoraria from the Society for Investigative Dermatology, and is a member of the board of directors for the International Psoriasis Council, receiving no honoraria.


References
1. Elmets CA, Lim HW, Stoff B, et al. Joint American Academy of Dermatology-

National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol. 2019;81(3):775-804. doi:10.1016/j.jaad.2019.04.042

2. Light treatment effectiveness (LITE) study (LITE). ClinicalTrials.gov identifier: NCT03726489. July 27, 2020. Accessed July 28, 2020. https://clinicaltrials.gov/ct2/show/NCT03726489

3. Lim HW, Feldman ST, Van Voorhees AS, Gelfand JM. Recommendations for phototherapy during the COVID-19 pandemic. 2020;83(1):287-288. doi:10.1016/j.jaad.2020.04.091

4. Aguilera P, Gilaberte Y, Pérez-Ferriols A, et al. Recomendaciones del Grupo Español de Fotobiología de la AEDV en referencia al manejo de las unidades de fototerapia durante la pandemia por SARS-CoV-2. Actas Dermosifiliogr. Published online July 15, 2020. doi:10.1016/j.ad.2020.07.001

5. Lytle CD, Sagripanti JL. Predicted inactivation of viruses of relevance to biodefense by solar radiation. J Virol. 2005;79(22):14244-14252. doi:10.1128/JVI.79.22.14244-14252.2005

6. Sagripanti JL, Lytle CD. Estimated inactivation of coronaviruses by solar radiation with special reference to COVID-19. Photochem Photobiol. 2020;96(4):731-737. doi:10.1111/php.13293

7. Heßling M, Hönes K, Vatter P, Lingenfelder C. Ultraviolet irradiation doses for coronavirus inactivation - review and analysis of coronavirus photoinactivation studies. GMS Hyg Infect Control. 2020;15:Doc08. doi:10.3205/dgkh000343.

8. Fisher EM, Shaffer RE. A method to determine the available UV-C dose for the decontamination of filtering facepiece respirators. J Appl Microbiol. 2011;110(1):287-295. doi:10.1111/j.1365-2672.2010.04881.x

9. Mills D, Harnish DA, Lawrence C, Sandoval-Powers M, Heimbuch BK. Ultraviolet germicidal irradiation of influenza-contaminated N95 filtering facepiece respirators. Am J infect Control. 2018;46(7):e49-e55. doi:10.1016/j.ajic.2018.02.018

10. Cadnum JL, Li DF, Redmon SN, John AR, Pearlmutter B, Donskey CJ. Effectiveness of ultraviolet-c light and a high-level disinfection cabinet for decontamination of N95 respirators. Pathog Immun. 2020;5(1):52-67. doi:10.20411/pai.v5i1.372

11. Hamzavi IH. SkinSerious: applying phototherapy expertise to the COVID-19 crisis. American Academy of Dermatology. Accessed July 24, 2020. https://www.aad.org/skinserious/stories-hamzavi-ramesh

12. Lindsley WG, Martin SB Jr, Thewlis RE, et al. Effects of ultraviolet germicidal irradiation (UVGI) on N95 respirator filtration performance and structural integrity. J Occup Environ Hyg. 2015;12(8):509-517. doi:10.1080/15459624.2015.1018518

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