Dr. Elizabeth Buzney discusses the role phototherapy continues to play in dermatology as an effective and safe treatment option for psoriasis and other skin diseases.
“I’m just going to get right to the punchline. It’s unequivocally, yes. There is a role for phototherapy in 2023, despite this being an era of biologics and small molecules,” said Elizabeth A. Buzney, MD, who presented “Is there a role for phototherapy in 2023?” during the Phototherapy and Photoprotection session at the American Academy of Dermatology (AAD) Annual Meeting 2023 in New Orleans.
While it’s no longer the case that psoriasis is the most common diagnosis among patients getting in-office phototherapy, the treatment option is safe, effective, and should be offered to patients, said Dr. Buzney.
“If you look at the [psoriasis area and severity index] PASI 75 and PASI 90 and compare phototherapy with where it fits in with biologics and small molecules, it is not as effective and does not kick in as quickly as these newer molecules, but it still works.”
In fact, efficacy compares with some biologics, said Dr. Buzney.
“… in terms of PASI 75, phototherapy is right there above ustekinumab and for PASI 90 it’s above tildrakizumab.”
There are times when phototherapy is a particularly good option in psoriasis, she said.
“One … is when patients have just a few small plaques. In that case, do you really want to give them a biologic or systemic medication for something that is just a small body surface area? So targeted phototherapy is an important modality.”
The other is for a synergistic effect, said Dr. Buzney.
“Many studies have shown that phototherapy is synergistic with biologics. For a patient who is not responding or not responding as well as you would like and you don’t want to switch them or maybe you can’t switch them for insurance reasons, you could add phototherapy.”
Potential Candidates
Biologics and small molecules are not for everyone, said Dr. Buzney.
“They’re extremely expensive to the health care system. They’re $40,000 to $60,000 a year for these patients. They require initial testing and potentially continued lab testing and monitoring. There is the infrequent risk of severe infection. And [especially with the older biologics and small molecules] there are risks to patients with HIV, TB, and hepatitis. There is concern for impact on patients with recent solid organ tumors. And they’re most likely safe during pregnancy and lactation but the information is limited.”
Xeroderma pigmentosum and concurrent cyclosporin use are the only absolute contraindications for narrowband UVB, according to Dr. Buzney.
“You can give a patient narrowband UVB even if they have a history of lupus … or a history of melanoma or multiple nonmelanoma skin cancers. You can also treat patients that are pregnant, lactating, and you can treat children.”
Barriers for phototherapy use are cost and convenience, said Dr. Buzney.
“Phototherapy is a time-consuming treatment. You have to commute to a center multiple times a week. You might have to pay copays or parking. And you might have to go to a public space, which was an issue during COVID.”
Patients’ increasing use of phototherapy at home, which studies have shown is as safe and effective as in-office therapy, helps to overcome some but not all challenges, said Dr. Buzney.
“Not every patient is a candidate for home phototherapy. They have to know what they’re doing. They have to be able to have a device in their home. They have to have a home.”
Beyond Psoriasis
Phototherapy is an important treatment for many other diagnoses, according to Dr. Buzney.
“For eczema, it’s still a very good treatment. I will say that if you compare phototherapy efficacy rates with those of dupilumab or upadacitinib, which are our two most commonly used molecules, the efficacy from phototherapy is not as good but it’s not bad. I usually quote around 40% to 60% clearance with narrowband UVB versus [according to a recent study] 70% with upadacitinib and 60% with dupilumab.”
Finally, according to Dr. Buzney, phototherapy can be for many diagnoses that have few if any effective medications, including contact dermatitis, cutaneous T-cell lymphoma, vitiligo, granuloma annulare, urticaria, lichen planus, and lichen planus pilaris.
