key: cord-0868629-xs52de9w authors: Torres, Angeli Eloise E.; Lyons, Alexis B.; Hamzavi, Iltefat H.; Lim, Henry W. title: ROLE OF PHOTOTHERAPY IN THE ERA OF BIOLOGICS date: 2020-04-24 journal: J Am Acad Dermatol DOI: 10.1016/j.jaad.2020.04.095 sha: f3da24a2ddaffdc6ea23fb36b12a6f2c8a6309c6 doc_id: 868629 cord_uid: xs52de9w ABSTRACT Phototherapy is a safe and effective treatment for many dermatologic conditions. With the advent of novel biologics and small molecule inhibitors, it is important to critically evaluate the role of phototherapy in dermatology. Surveys have shown that many dermatology residency programs do not dedicate time to teach residents how to prescribe or administer phototherapy. Limitations of phototherapy include access to a center, time required for treatments, and insurance approval. Home phototherapy, a viable option, is also underutilized. However, it should be emphasized that modern phototherapy has been in use for over 40 years, has an excellent safety profile, and does not require laboratory monitoring. It can be safely combined with many other treatment modalities including biologics and small molecule inhibitors. In addition, phototherapy costs significantly less than these novel agents. Dermatologists are the only group of physicians who have the expertise and proper training to deliver this treatment modality to our patients. Therefore, in order to continue to deliver high quality, cost-effective care, it is imperative that phototherapy be maintained as an integral part of the dermatology treatment armamentarium. Phototherapy is a safe and effective treatment for many dermatologic conditions. With the advent 26 of novel biologics and small molecule inhibitors, it is important to critically evaluate the role of 27 phototherapy in dermatology. Surveys have shown that many dermatology residency programs 28 do not dedicate time to teach residents how to prescribe or administer phototherapy. Limitations 29 of phototherapy include access to a center, time required for treatments, and insurance approval. 30 Home phototherapy, a viable option, is also underutilized. However, it should be emphasized 31 that modern phototherapy has been in use for over 40 years, has an excellent safety profile, and 32 does not require laboratory monitoring. It can be safely combined with many other treatment 33 modalities including biologics and small molecule inhibitors. In addition, phototherapy costs 34 significantly less than these novel agents. Dermatologists are the only group of physicians who 35 have the expertise and proper training to deliver this treatment modality to our patients. 36 Therefore, in order to continue to deliver high quality, cost-effective care, it is imperative that 37 phototherapy be maintained as an integral part of the dermatology treatment armamentarium. In other parts of the world, phototherapy utilization was higher than in the U.S. In 63 Australia, a nationwide survey of practicing dermatologists published in 2002 revealed that 71% 64 of respondents provided phototherapy, and among them, almost 90% had their own treatment 65 facilities. 7 In France, the number of UV treatments administered annually increased by 12% from 66 2007-2010 -nearly a decade after biologics were first introduced; however, follow-up data 67 (2013-2016) saw a decline of the same by 15%, which was attributed to delays in initiation of 68 biologic therapy. 8 Although "clinical inertia" was suggested as a reason for this delay, 8, 9 it is 69 also worthwhile to consider that many guidelines do not endorse biologics as first-line agents and 70 a stepwise approach is still advocated. 10 71 72 A 2017 study by Goyal et al. showed that there was a disparity between the demand for 74 phototherapy and the time devoted to learning it during residency. Responses obtained from 75 dermatology program directors across the U.S. revealed that a majority (67%) regarded their 76 phototherapy training as inadequate, which was primarily attributed to time deficiency. 11 77 A cross-sectional survey among U.S. dermatology residents, published in 2015, revealed 78 that about 59% did not obtain any hands-on phototherapy training, while 42% have never 79 observed phototherapy at all. Less than half of the residents felt that they could comfortably 80 administer NB-UVB unsupervised, and less than 20% were comfortable with administering other 81 modalities (excimer laser, PUVA, and BB-UVB). 12 76% were not comfortable with prescribing outpatient and home phototherapy, respectively. This 84 discomfort stemmed from a lack of exposure and is significant because dermatology trainees 85 who do not develop enough confidence to prescribe phototherapy during residency are less likely 86 to do so in practice. 13 immunosuppression. 14-16 95 Phototherapy has been used successfully to treat many skin diseases. A partial list is 96 shown in Table I . Among these, phototherapy for psoriasis has the most data. The different 97 modalities that can be used for psoriasis are BB-UVB, NB-UVB, excimer light or laser, and 98 PUVA (oral, topical, hand-foot soak, and bath/full body soak). 17 BB-UVB is rarely used 99 nowadays and has largely been replaced by NB-UVB due to the latter's better efficacy. 18 100 (79%) but caused symptomatic erythema and blistering in 17% of patients. NB-UVB attained a 106 68% CR and was better tolerated (side effects in 7.8%), while bath PUVA was the least effective 107 (58% CR) and least tolerated (side effects in 21%). Hence, although oral PUVA is more 108 efficacious, better tolerability makes NB-UVB a preferred first-line phototherapy modality. 17 In The price of treatment is a reality that must be considered when formulating a 184 management plan; and for chronic skin conditions, this may entail lifelong expenditures. 185 According to a study in Scotland, the average price for a course of NB-UVB is £257, while 186 topical medications cost £128 annually per patient. Implementing NB-UVB resulted in a 40% 187 reduction in cost (£50.74 per patient annually) due to less need for medications. 32 In practice, treatments are often combined to enhance efficacy when rapid suppression of 208 disease activity is desired or when monotherapy is insufficient to achieve and maintain control. 209 Several reviews and guidelines on psoriasis treatment have reported on the combination of 210 phototherapy with various topical drugs, traditional systemic agents, and biologics. 14, 16, 38, 39 211 With each medication having its own side effects, enhanced toxicity from combining two or 212 more modalities is a possibility. Contrarily, some combinations of medications may lower the 213 chances of long-term adverse effects by reducing the cumulative dose of either modality alone or 214 The concomitant administration of acitretin with NB-UVB has been found to hasten 217 clinical response, reduce the required acitretin dose, and decrease the number of phototherapy 218 sessions by approximately 20% thereby lowering the cumulative UV dose and theoretical risk for 219 photocarcinogenesis. 14, 38, 40 Similar effects have been observed with acitretin plus PUVA, and 220 given the established skin cancer risk with this modality, the co-administration of an oral retinoid 221 is particularly valuable. 40-43 Since retinoids have a keratolytic effect, phototherapy dose 222 escalations must be proceeded with cautiously when using this combination. 14 Most protocols 223 recommend UV dose reduction by 33%. 224 Several studies have shown that NB-UVB in conjunction with biologics is safe, 225 synergistic, and well-tolerated, although long-term data on these combinations have not been Phototherapy remains an indispensable treatment option for many cutaneous diseases. Its 265 versatility, cost-effectiveness, and unparalleled safety makes it a viable first-line treatment or 266 adjunct when other treatment regimens fall short. Just as there are numerous indications for 267 phototherapy alone, there are a wide variety of modalities with which it can be combined. As 268 dermatologic management becomes more individualized and costly, improved access to this 269 treatment modality through expanding residency training curriculums and prescribing home 270 devices will prove that even in the era of biologics, phototherapy will stand the test of time. 271 Dermatologists are the only group of physicians who have the knowledge and expertise to 272 supervise the delivery of phototherapy. Therefore, it is essential that we as a specialty continue to 273 make sure this treatment option is available to our patients. History of phototherapy in dermatology History of Human Photobiology United States of America: Informa Healthcare USA, Inc Photochemotherapy of psoriasis with 281 oral methoxsalen and longwave ultraviolet light Excimer Laser for Cutaneous Conditions Phototherapy utilization for 285 psoriasis is declining in the United States Trends in phototherapy utilization among Medicare 287 beneficiaries in the United States Survey of phototherapy practice by dermatologists in France: quantitative data (2007-2016) from the National Health Insurance Register Changing Provider Behavior in the Context of Chronic 294 Disease Management: Focus on Clinical Inertia Systemic Therapies, and Biologic Agents Perceptions 299 of U.S. dermatology residency program directors regarding the adequacy of phototherapy 300 training during residency A cross-sectional 303 survey study to evaluate phototherapy training in dermatology residency. Photodermatology, 304 photoimmunology & photomedicine Training for prescribing in-office and 306 home phototherapy Phototherapy of psoriasis in the era of biologics: still in Phototherapy of Psoriasis, a Chronic Inflammatory Skin Disease psoriasis, and the age of biologics Systematic review of UV-based 314 therapy for psoriasis UV-based therapy :190-8. urticaria with UVA1 hardening in three patients Phototherapy 322 in dermatology: A call for action Joint AAD-NPF 324 guidelines of care for the management and treatment of psoriasis with biologics Comparison of Biologics 327 and Oral Treatments for Plaque Psoriasis: A Meta-analysis Biologics and Psoriasis: The Beat Goes On Efficacy 331 of psoralen plus ultraviolet A therapy vs. biologics in moderate to severe chronic plaque 332 psoriasis: retrospective data analysis of a patient registry Patient-334 reported outcomes of adalimumab, phototherapy, and placebo in the Vascular Inflammation in Psoriasis Trial: A randomized controlled study Distinguishing Myth from Fact: Photocarcinogenesis and 337 Incidence of skin cancers in 3867 339 patients treated with narrow-band ultraviolet B phototherapy Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of 344 psoriasis and guidelines of care for the treatment of psoriasis with biologics Biologic Treatment Options for Pediatric 347 Psoriasis and Atopic Dermatitis Narrowband 349 ultraviolet B treatment for psoriasis is highly economical and causes significant savings in cost 350 for topical treatments Recent trends in systemic psoriasis treatment costs Managing the dose escalation of biologics in an era of cost 354 containment: the need for a rational strategy A guide to prescribing home phototherapy for patients with 356 psoriasis: the appropriate patient, the type of unit, the treatment regimen, and the potential 357 obstacles A cross-sectional, comparative study of home vs 359 in-office NB-UVB phototherapy for vitiligo Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management 365 and treatment of psoriasis with phototherapy Combining 367 biologic and phototherapy treatments for psoriasis: safety, efficacy, and patient acceptability Acitretin in combination with UVB or PUVA Guidelines 372 of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for 373 the treatment of psoriasis with phototherapy and photochemotherapy Photochemotherapy for 376 severe psoriasis without or in combination with acitretin: a randomized, double-blind comparison 377 study Oral retinoid use reduces cutaneous squamous cell carcinoma risk in 379 patients with psoriasis treated with psoralen-UVA: a nested cohort study Etanercept plus 382 narrowband ultraviolet B phototherapy of psoriasis is more effective than etanercept 383 monotherapy at 6 weeks Treatment with 311-nm ultraviolet B enhanced response of psoriatic lesions in ustekinumab-389 treated patients: a randomized intraindividual trial ABSTRACT: