Review of an established UK home phototherapy service 1998-2011: improving access to a cost-effective treatment for chronic skin disease.

OBJECTIVES: To review the Tayside home phototherapy service, including numbers of patients treated, diagnoses and outcomes, side-effects and safety, cost-effectiveness and absolute costs. To consider why home or outpatient phototherapy is not available to all patients who might benefit and how this could be addressed. STUDY DESIGN: Observational and cost analysis. METHODS: Analysis of the Tayside home phototherapy database 1998 and 2011, home phototherapy patient questionnaires, outcome data, costs and a comparison with outpatient phototherapy. Review of literature and current national guidelines for phototherapy, traditional systemic and biologic therapies for psoriasis. RESULTS: 298 courses of home narrowband UVB (NB-UVB) phototherapy were undertaken by 212 patients between 1998 and 2011, five courses in 1998 increasing to 36 in 2011. The main diagnoses treated were psoriasis (72%), atopic dermatitis (8%), and desensitization of photodermatosis (7%). For psoriasis, 74.5% achieved clearance or minimal residual activity in a median of 30 exposures (range 10-60). The estimated costs to the hospital ranged from £229 to £314 per course (£307 to £422 per effective course for psoriasis), compared with £114 for out-patient therapy (£149 per effective course for psoriasis). The total cost to society (hospital and patient costs) is around £410 per course, compared to an estimated £550 for outpatient therapy for this group of patients. Treatment was well tolerated, erythema rates were similar to outpatient therapy, there were no complaints and the vast majority would choose home over outpatient phototherapy if required in the future. CONCLUSIONS: Hospital supervised home phototherapy appears as safe and effective as outpatient therapy and provides equality of access for patients who cannot attend for outpatient therapy. These patients may otherwise be inadequately treated or given more costly and higher risk systemic therapies, particularly for psoriasis. Commissioners and clinicians involved in dermatology services should provide accessible phototherapy for all patients who might benefit, utilizing home phototherapy where outpatient access is not possible.

Self-administration of hospital-based narrowband ultraviolet B (TL-01) phototherapy: a feasibility study in an outpatient setting.

BACKGROUND: Self-administration of narrowband (TL-01) ultraviolet (UV)B phototherapy by patients at home is a safe and effective mode of treatment. Could selected patients self-administer phototherapy in hospital? OBJECTIVES: To assess the feasibility of outpatient self-administration of UVB phototherapy as a potential service development. METHODS: A total of 20 patients with psoriasis (n = 15) and eczema (n = 5) (13 female, mean age 32 years, range 17-56 years) were included in this pilot project. Patients underwent a training programme over 2 days, which included a minimal erythemal dose test and supervised treatment, prior to commencing self-administration of phototherapy. Questionnaires were used to gather feedback from patients and staff. RESULTS: Treatment data were collected for 18 of the 20 patients. The mean number of exposures was 25 (range 3-45), and the mean cumulative dose was 16 J cm(-2) (range 0·23-41·27 J cm(-2) ). No unexpected adverse effects were noted. These results were similar to those of a sample group of outpatients who had nurse-administered UVB phototherapy, for whom the mean number of exposures was 24 (range 4-49) and the mean cumulative dose was 17 J cm(-2) (range 0·53-71·16 J cm(-2) ). Thirteen patients completed the questionnaires. All concluded that the training programme sufficiently prepared them for self-administering phototherapy, and 12 reported that they would be happy to self-administer treatment in the future. CONCLUSIONS: Self-administration of UVB phototherapy is practicable, safe and effective for most selected patients. This mode of treatment provides training and support for patients to gain more control over management of their skin disease, empowering them to take an active role in their treatment. Self-administration of UVB phototherapy by outpatients provides an intermediate level of care between nurse-administered hospital phototherapy and self-administered home phototherapy.

Ultraviolet A1 phototherapy: a British Photodermatology Group workshop report.

Whole-body ultraviolet (UV)A1 (340-400 nm) phototherapy was first introduced 30 years ago, but is currently available in the UK in only three dermatology departments. A workshop to discuss UVA1 was held by the British Photodermatology Group in May 2009, the aim of which was to provide an overview of UVA1 phototherapy and its role in practice, and to identify areas in which further studies are required. The conclusions were that UVA1 phototherapy is an effective treatment in several inflammatory skin diseases, including localized scleroderma and atopic eczema (AE); however, deficiencies and limitations exist in the published evidence base. For most diseases, such as AE, other treatments also exist, which are generally more effective than UVA1. However, for some diseases, particularly morphoea, the evidence of efficacy is stronger for UVA1 than for other treatments. Acute adverse effects of UVA1 are minimal. The risk of long-term adverse effects, particularly skin cancer, is unknown. Medium to high doses of UVA1 are needed for efficacy in most situations, but the equipment to deliver such doses is large, expensive and difficult to install. UVA1 is currently underprovided, and the recommendation of the workshop is that more tertiary centres should have access to UVA1 phototherapy in the UK.

Within-patient right-left blinded comparison of diode (810 nm) laser therapy and intense pulsed light therapy for hair removal.

Excessive facial hair in women can cause significant psychological distress. A variety of treatment methods are available, including lasers and, more recently, intense pulsed light (IPL) sources. There are very few studies comparing laser and IPL devices. The purpose of our study was to compare a laser diode device with an IPL, using a within-patient, right-left, assessor-blinded, controlled, study design. Hair counts were made, using coded close-up photographs. Treatments were carried out on three occasions at 6-week intervals, and a final assessment was made 6 weeks following the third treatment. Patient self-assessment was also included. Nine women were recruited, and seven completed the study. Average hair counts in a 16 cm(2) area before and after treatment were, respectively, 42.4 and 10.4 (laser), 38.1 and 20.4 (IPL), 45.3 and 44.7 (control). Both laser and IPL reduced the hair count substantially; laser vs control was significant at P=0.028, but IPL vs control had P=0.13, suggesting that more subjects or more treatments were required if statistical significance were to be achieved. Despite subjecting the patients to higher pain scores and more inflammation, laser was preferred by five patients; two preferred IPL and one had no preference.

A randomized controlled comparison of the efficacy of Dead Sea salt balneophototherapy vs. narrowband ultraviolet B monotherapy for chronic plaque psoriasis.

BACKGROUND: Dead Sea (DS) salt solution soaks are used in combination with narrowband ultraviolet B (NB-UVB) to treat psoriasis in many centres, particularly in continental Europe. No previously published controlled study has assessed DS salt + NB-UVB balneophototherapy. OBJECTIVES: To compare DS salt balneophototherapy with NB-UVB monotherapy for chronic plaque psoriasis. METHODS: Sixty patients with chronic plaque psoriasis participated in this paired, controlled study, with pretreatment DS salt soaks randomly allocated to each participant's right or left study limb. Psoriasis severity was assessed with a Scaling, Erythema and Induration score by a blinded observer. Assessments were weekly during the therapy course, and thereafter 8-weekly until relapse or for up to 1 year after clearance. RESULTS: The mean area under the psoriasis severity-time curves during treatment was not detectably lower with DS salt balneophototherapy than with NB-UVB monotherapy (P = 0.099). The psoriasis severity score fell slightly more from beginning to end of courses with DS salt balneophototherapy than with NB-UVB monotherapy (P = 0.019). There was no detectable difference in times to relapse. CONCLUSIONS: In this population the addition of pretreatment DS salt soaks to NB-UVB did not result in a clinically important improvement in clearance of psoriasis.

Photogenotoxicity of hypericin in HaCaT keratinocytes: implications for St. John's Wort supplements and high dose UVA-1 therapy.

Extract of St. John's Wort (Hypericum perforatum) is commonly used as natural remedy for treatment of mild to moderate depression. However, it contains a powerful photoactive component, hypericin, which can cause a severe photodermatitis when eaten by grazing animals (hypericism). In humans, there is evidence that supplementation with St. John's Wort can reduce the minimal erythemal dose (MED) in patients undergoing high dose UVA-1 phototherapy. This is a recent development in phototherapy where the most erythemogenic parts of the UVA spectrum are filtered out, allowing delivery of higher doses of the longer wavelengths of UVA. Although current published evidence suggests that the plasma levels of hypericin are unlikely to cause clinical phototoxicity, it has been established that photoactive compounds can cause DNA damage at sub-toxic and sub-erythemal doses, the effects of which might not be apparent for many years after the event. The present study used HaCaT keratinocytes to investigate the photoclastogenic ability of hypericin on irradiation with UVA. The results show that although the combination of hypericin and UVA light increased the genotoxic burden, when all factors are taken into account, the risk of significant photogenotoxic damage incurred by the combination of Hypericum extracts and UVA phototherapy may be low in the majority of individuals.

Treatment of superficial cutaneous vascular lesions: experience with the KTP 532 nm laser.

Whilst most facial telangiectasias respond well to short-pulse-duration pulsed dye laser therapy, studies have shown that for the treatment of larger vessels these short-duration pulses are sub-optimal. Long-pulse frequency-doubled neodymium:YAG lasers have been introduced with pulse durations ranging from 1-50 ms and treatment beam diameters of up to 4 mm. We report the results of KTP/532 nm laser treatment for superficial vascular skin lesions. The aim was to determine the efficacy of the KTP/532 nm laser in the treatment of superficial cutaneous vascular lesions at a regional dermatology centre in a 2 year retrospective analysis. Patients were referred from general dermatology clinics to a purpose-built laser facility. A test dose was performed at the initial consultation and thereafter patients were reviewed and treated at 6 week intervals. Outcome was graded into five classifications by the patient and operator independently based on photographic records: clear, marked improvement, partial response, poor response, and no change or worsening. Over the 2 year period, 204 patients with 246 diagnoses were treated [156 female; median age 41 (range 1-74) years; Fitzpatrick skin types I-III]. Equal numbers of spider angioma (102) and facial telangiectasia (102) were treated. Of those patients who completed treatment and follow up, 57/58 (98%) of spider angiomas and 44/49 (90%) of facial telangiectasia markedly improved or cleared. Satisfactory treatment outcomes, with one clearance and two partial responses, occurred in three of five patients with port-wine stain. Few patients experienced adverse effects: two declined further treatment due to pain, and a small area of minimal superficial scarring developed in one case. Two patients developed mild persistent post-inflammatory hyperpigmentation, and one subject experienced an episode of acute facial erythema, swelling and blistering after one treatment. The KTP/532 nm frequency-doubled neodymium:YAG laser is a safe and effective treatment for common superficial cutaneous vascular lesions in patients with Fitzpatrick skin types I-III.

An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group Workshop Report.

Summary These guidelines for use of narrowband (TL-01) ultraviolet B have been prepared for dermatologists by the British Photodermatology Group on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment of patients with a variety of dermatoses and photodermatoses, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of background photobiology.

Taking treatment to the patient: development of a home TL-01 ultraviolet B phototherapy service.

BACKGROUND: While most patients requiring phototherapy can attend for hospital-based out-patient ultraviolet (UV) B therapy, a significant number cannot attend because of geographical, work, economic and other reasons. OBJECTIVES: To determine whether there was a need for home phototherapy in the Tayside area and, if so, to establish protocols and then to assess if such a service would be workable. METHODS: Patients referred from dermatology out-patient clinics in Tayside for narrow-band UVB (TL-01) phototherapy completed a pilot questionnaire that was followed by a two-phase project. In phase 1, patients with psoriasis were trained to use the home phototherapy equipment (HoPE) within the hospital department under nursing supervision while a teaching package and protocols were developed. In phase 2, home phototherapy was made available for patient use in the community, supported by a specialist home phototherapy nurse. Waldmann UV100 home therapy units were used, with accurate dosimetry. Detailed treatment records were kept and questionnaires were used to assess acceptability and costs of therapy. RESULTS: Fifty-two pilot questionnaires were completed. Forty-two per cent of respondents found hospital phototherapy inconvenient and 75% felt phototherapy at home would be helpful. In phase 1, seven of 10 patients trained to use the HoPE completed therapy with the HoPE unit alone, reaching minimal residual activity (MRA) or clearance in a median of 18 exposures (median dose 10.38 J cm-2). In phase 2, 32 courses of home phototherapy were given to 30 patients. Of 23 with psoriasis, 18 reached clearance or MRA in a median of 22.5 exposures (median dose 9.84 J cm-2). Although self-reported erythema rates appeared higher than expected, all post-treatment questionnaire respondents would choose home phototherapy over hospital therapy if required in the future. CONCLUSIONS: UVB (TL-01) home phototherapy is a useful practical development that has fulfilled a need in our catchment area. Where appropriate training and support teams are available it appears to be similar in effectiveness to hospital therapy, to be safe and to be cost-effective for patients.

Home phototherapy: report on a workshop of the British Photodermatology Group, December 1996.

Phototherapy is a popular and effective treatment for many patients with skin diseases. However, repeated journeys to hospital for phototherapy can be inconvenient and expensive. If it were available, many patients might prefer home-based phototherapy as long as it was safe and effective. Indeed, many psoriasis patients already self-treat with ultraviolet A sunbeds at home. This report represents a consensus view from a British Photodermatology Group workshop held in December 1996, the purpose of which was to examine the potential role of home-based phototherapy in dermatological practice. We conclude that home-based therapy represents a suboptimal treatment with greater attendant risks than phototherapy in a hospital environment. The level of medical supervision of the home treatment is crucial to its safety and effectiveness. Until further studies are forthcoming, home phototherapy should be largely restricted to those with overwhelming difficulties in attending hospital.

Clear ultraviolet blocking lenses for use by PUVA patients.

It is well recognized that patients receiving photochemotherapy (PUVA) need to wear UV-blocking sunglasses on the day of ingestion of 8-methoxypsoralen. For many patients the wearing of tinted sun-glasses causes difficulties because they interfere with colour perception, reduce definition in conditions of low background light and often because they are considered 'cosmetically unacceptable'. In this study the UV-blocking properties of a number of lenses with little or no tint were assessed. The following lenses or lens coatings were found to be suitable for use by PUVA patients: Orcolite UV 400, Orma UVX, Rodenstock Lambda 400, Sola UV Gard 400 and Polaroid polarizing lenses.

Photochemotherapy. A reappraisal of its use in dermatology.

Oral psoralen photochemotherapy was introduced for the treatment of psoriasis in the mid-1970s. Since then it has become an established technique, generally giving good clearance rates of affected areas, and its usefulness has extended to treatment of other conditions. It is popular with patients but possible ocular complications must be avoided and the potential for carcinogenesis should be recognised. Although essentially palliative rather than curative, it has achieved major successes in the treatment of psoriasis and cutaneous T-cell lymphoma, and is also of benefit in the management of vitiligo. This article reviews over a decade of clinical and laboratory findings. Therapeutic responses are summarised and consideration is given to the protection of patients and staff.

Pharmacokinetics, toxicity, and short-term results of cisplatin hyperthermic isolated limb perfusion for soft-tissue sarcoma and melanoma of the extremities.

Fifty-nine patients with melanoma or soft tissue sarcoma of the extremities underwent hyperthermic isolated limb perfusion utilizing cisplatin and wide local excision. Doses of cisplatin ranged from 0.75 to 2 mg/kg. The mortality and morbidity rates were 0 and 6.8 percent, respectively. Pharmacokinetic studies indicate that cisplatin is rapidly bound to perfused tissues and remains bound for 1 month. Maximum tumor response in sarcomas occurs 1 to 2 weeks after perfusion, compared with 1 month after perfusions with l-phenylalanine mustard and actinomycin D. Local and regional recurrence rates were 0 and 3.4 percent, respectively, at 1 year. Further studies of hyperthermic limb perfusions with cisplatin are warranted.

The suitability of sunglasses used by patients following ingestion of psoralen.

We have investigated the types of eyewear which patients on photochemotherapy have obtained, and determined their suitability for providing adequate protection. Fifty-eight pairs of sunglasses from 53 patients were assessed. Spectral transmission was measured between 200 nm and 800 nm at 10 nm intervals. Thirty-eight pairs of glasses (66%) were found to be satisfactory. Particularly high UV transmission was recorded in 11 cases (19%), highlighting the need for increased awareness of the problem of ensuring that suitable protective eyewear is used.

Cutaneous and ocular side-effects of oral photochemotherapy: results of an 8-year follow-up study.

To determine the long-term cutaneous side-effects of oral photochemotherapy (PUVA), we examined 95 patients, 59 with psoriasis and 36 with mycosis fungoides (MF). These comprised 80% and 69% respectively of the patients with these disorders treated with PUVA in our department from 1977 to 1985. Two psoriatic patients had squamous carcinomas, both of whom had received high cumulative UVA doses and also methotrexate concurrently with PUVA. Six patients with MF had actinic keratoses. The mean age of these patients (69 years) was significantly greater than the mean age of the patients without actinic keratoses (54 years), but there was no significant difference in their cumulative UVA doses. No patients developed basal cell carcinomas or malignant melanoma. 'PUVA lentigines' were found in 46% of the patients. They were most frequent in patients currently being treated and in those who had received high cumulative UVA doses, but persisted for up to 7 years after discontinuing therapy. Seventy-one patients had yearly ophthalmological examinations, or a single examination at least 3 months after commencing PUVA. This examination included retinal function tests to detect any subclinical visual impairment. Five of these patients had cataract prior to PUVA therapy, and were significantly older (mean age 71 years) than those without cataract (mean age 53 years). Three patients (mean age 61 years) developed new lens opacities whilst receiving PUVA. However, none of these patients was considered to have cataract as none had impairment of visual acuity due to lens opacity. No patients without lens opacity developed evidence of subclinical visual impairment.