Kenneth B. Gordon, MD, asserted at MedscapeLive’s annual Las Vegas Dermatology Seminar, held virtually this year.
Dr. Kenneth Gordon
“In my practice, I’m using more and more home UVB, and there are a number of reasons for that. It’s more convenient and easier for the patient, as it’s getting more difficult for patients to give up time from work to come to the office. And I might add that, in this time of COVID-19, people don’t want to come to the office. It’s generally less expensive for patients because of copays, which increase the cost of UVB. And believe it or not, I believe it’s easier for the clinician as well. I write a prescription, the patient gets a number of treatments, and I don’t lose any sleep because I think it’s very difficult for patients to get into trouble with narrow-band UVB at home,” explained Dr. Gordon, professor and chair of the department of dermatology at the Medical College of Wisconsin, Milwaukee.
“There’s all sorts of insurance company silliness in getting this paid for, but if you do get it paid for, I think it’s a really effective way to treat psoriasis,” the dermatologist added.
A Dutch multicenter randomized trial demonstrated that home UVB phototherapy for psoriasis was equally safe and effective as outpatient UVB phototherapy, and with greater patient satisfaction.
Surveys show most dermatologists consider phototherapy their preferred treatment for patients with extensive psoriasis because its side effect profile is so benign, compared with that of systemic therapies, be they biologic agents or older drugs such as methotrexate or acitretin. Phototherapy is particularly popular for use in women of childbearing potential, since it’s a nonsystemic therapy.
And speaking of side effects, Dr. Gordon declared, “The risks of narrow-band UVB are sometimes, I believe, exaggerated.” Indeed, he considers the No. 1 side effect of office-based phototherapy to be the loss of productive time.
“Simply put, phototherapy in the office is very easy for me. I write a prescription, the tech takes care of it, and if there’s a problem I’m handy to see the patient. But for the patient, it’s very difficult. Whereas it might take only a few minutes to get the treatment in-office, it takes a lot of time to get to the office, and many patients don’t have transportation. So I think the loss of productive time with phototherapy has to be considered a side effect,” Dr. Gordon said.
Turning to the therapy’s other side effects, he said that although there is some degree of photoaging associated with narrow-band UVB – which is far and away the most commonly used form of phototherapy in the United States – it’s nothing close to the photoaging caused by PUVA.
“I don’t believe that PUVA, with all the destruction of the skin that you see with it, is a significant part of our treatment modalities today,” Dr. Gordon said.
Sunburn is a risk with narrow-band UVB, especially if the dose is ramped up too quickly. Reactivation of herpes simplex virus infection is a frequent problem, and one patients find especially concerning when it manifests as eruptions of cold sores on the face.
The side effect of narrow-band UVB of greatest interest to most patients and physicians is skin cancer. “This is an extremely controversial area,” the dermatologist observed.
Unlike with PUVA, there has never been a convincing study to show that narrow-band UVB is associated with significantly increased risks of keratinocyte carcinomas or melanoma. A large Scottish study found no significantly increased risk, but a modestly increased trend for more squamous cell carcinomas. How modest? The investigators calculated that it would require 50,000 psoriasis patients with a minimum of 100 narrow-band UVB treatments to be followed for 5 years in order to demonstrate a twofold increased risk of the malignancy.
“In other words, it takes an incredible number of patients to be able to see a difference in a skin cancer that we can relatively easily treat. That’s why when I see patients, I don’t emphasize the risk of skin cancer,” Dr. Gordon said.
Similarly reassuring was a Swedish study, which showed the skin cancer rate in UVB-treated psoriasis patients was no different than in the general population.
Guideline recommendations regarding UVB phototherapy and skin cancer risk are all over the map. French guidelines advise a maximum of 230 narrow-band UVB treatments. British guidelines recommend reducing narrow-band UVB exposure to skin areas with significant sun exposure. American guidelines leave the topic untouched, Dr. Gordon noted.
He reported having no financial conflicts of interest regarding his presentation, as neither he, the Medical College of Wisconsin, or its department of dermatology receive any payment for phototherapy services he prescribes. Those payments go to the hospital system where he works. MedscapeLive and this news organization are owned by the same parent company.