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SKIN CARE

This article looks at phototherapy, the forms of treatments available, the risks

and benefits, as well as the general practicalities involved in this mode of therapy. Community nurses are well placed to provide patients with information about treatment options available in secondary care for psoriasis and to answer any questions. Thus, having a clear understanding about phototherapy enables them to provide valuable information to reassure patients about alternative treatments for psoriasis.

WHAT IS PHOTOTHERAPY?

Sunshine has been used to treat skin conditions for many years. Over 3,500 years ago Egyptian and

The psoriatic patient treatment pathway: phototherapy

Tonia Goman

Indian healers used natural sunshine in conjunction with natural plant extracts (Monem and Mofty, 1948; Honigsmann, 2013). Although one of the oldest forms of treatment for psoriasis, it remains popular as it is considered a safe and effective option (Asztalos et al, 2012). Light therapy involves exposing the skin to wavelengths of ultraviolet (UV) light under medical supervision. Only the UVA and UVB spectrum is of value to treat skin conditions.

LIGHT SPECTRUM

UVA and UVB are the main cause of sun burn and skin cancer which can cause premature ageing of skin, eye damage, including cataracts, and skin cancers (Skin Cancer Foundation, 2013). They are also known to suppress the immune system, which can reduce the natural response to protect from the development of skin cancer.

Although known to be damaging to skin, these rays can be used

Tonia Goman, dermatology specialist nurse, (inflammatory skin conditions) and lead phototherapy nurse, Bristol Dermatology Centre, Bristol Royal Infirmary; joint-chair of British Dermatology Nurse Group (BDNG) phototherapy sub-group; skin camouflage practitioner

This series focuses on the patient treatment pathway in managing psoriasis as laid out by the National Institute for Health and Care

million people within the UK, necessitating up to 60% of these patients requiring a form of secondary care input (Jackson, 2012). Secondary care is often required to provide further topical treatment advice, but equally this also falls within the remit of all healthcare professionals, such as community nurses, who have face-to-face contact with patients with psoriasis. As these topical treatments may not manage the symptoms of psoriasis alone, referral to dermatology departments where more specialist treatments can be prescribed may be needed.

forms of treatment under this umbrella, with which community nurses should be familiar.

KEYWORDS:Dermatology Psoriasis Phototherapy Treatments

Figure 1.The psoriasis treatment pathway (adapted from NICE, 2016).

Person with psoriasis

Principles of care

Assessment

Topical therapy

Specialist referral

Systemic biologic therapy

Phototherapy Systemictherapy

beneficially to treat a multitude of skin conditions, including psoriasis, and are used in many dermatology centres. NICE guidelines (2017; 2018) also suggest offering this mode of therapy before considering systemic treatments.

How does UVB work?When UVB penetrates the skin, it slows down cell growth, which, in turn, slows the development of scaling commonly associated with psoriasis. The immune system is suppressed within the skin and the

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production of vitamin D is increased, (Juzieniene, 2016). Narrowband UVB, also known as TLO1 due to the bulbs used, employs a specific range of UV light that is beneficial without exposing the skin to unnecessary wavelengths (Psoriasis and Psoriatic Arthritis Alliance [PAPAA], 2016a).

What is UVB therapy?There are two forms of UVB treatments, broadband and narrowband UVB.

Broadband UVB was widely used until around 15–20 years ago, and had been used from the 1920s using the whole of the UVB spectrum (289nm–320nm) (Oakley, 2015). The main purpose was to treat guttate and plaque psoriasis that had not been controlled with use of topical treatments, or was too widespread.

Narrowband UVB is now more commonly used. It became available in 1981 and has steadily taken over from broadband UVB, as it has become more effective in clearing psoriasis. The spectrum offers a more precise wavelength of the UVB spectrum (300nm and 313nm). This treatment is generally provided in a hospital setting by trained nurses, but in some areas of the country it is still administered by physiotherapists. Narrowband UVB allows patients to receive therapeutic phototherapy doses with less risk of severe burning or potentially harmful exposure to UV. Pregnant ladies can be treated with UVB, but not UVA (Oakley, 2008; Patricia et al, 2015).

Often patients will be tested

What is UVA therapy?Photochemotherapy or PUVA can also be effective in treating psoriasis. It was introduced in the 1970s and is a combination therapy which involves psoralen, pronounced as soralyn – silent ‘p’, and then exposing the skin. UVA on its own is not effective. Psoralen is a photosensitiser that is derived from plants. Psoralen can be used in tablet form, soaks/baths, gel or even paint. It is worth noting that UVA is present in fluorescent lighting and can penetrate glass and light fabrics, thus when taking systemic psoralen these need to be avoided.

PUVA tends to penetrate deeper through the skin and is therefore more effective for moderate or thicker plaque psoriasis. It is often used as second-line treatment, e.g. if TLO1 does not clear the psoriasis enough, PUVA can be offered (British Association of Dermatologists [BAD], 2015). As with UVB, PUVA suppresses cell growth, but penetrates deeper through the skin’s layers. It is also beneficial to treat areas where the skin is thicker, such as the palms of the hand and soles of the feet. Specific machines can be used to target affected areas of the body, rather than having to expose the whole body.

Tablet PUVA For PUVA tablets to be effective, the dose will be prescribed according to the patient’s weight. Timing is aimed at when the sensitivity is at its peak before entering the phototherapy cabinet, usually two or three hours, depending on the type of tablet provided. There are two strengths available. The more commonly used dose is 8-MOP, otherwise known as methoxypsoralen. Treatment is given in most departments twice weekly. 5-MOP is potentially more gentle on the stomach, reducing side-effects of nausea or vomiting and usually needs to be taken three hours before treatment. The patient should be entering the cabinet at the time the medication is at its most potent.

Photosensitivity occurs immediately, so protection is essential, particularly eye protection and covering exposed skin.

before starting their UV therapy to check their sensitivity to the light. A small area of usually unexposed skin will receive a range of 6–10 different doses of UVB, which is likely to respond by becoming pink/red. The area which responded with the minimal, perceptible pinkness will determine the dose chosen. This test is known as minimal erythema dose or MED (PAPAA, 2016b).

This form of treatment is effective, although can be time-consuming for patients, as they are required to attend two to three times weekly for approximately six to eight weeks of treatment. The time they are in the cabinet is relatively quick, starting off for a few seconds and increasing to minutes. Doses are measured in joulage. It is not a cure, but is usually effective enough to manage the remaining level of active psoriasis with topical treatments. The intention, as advised by DermNet NZ, is to be 75% clear of active psoriasis, (DermNet NZ, 2007). Due to the risk factors involved, there is a limit as to how much light treatment a patient can have. Therefore, all doses and treatments should be documented for accumulation purposes.

Other topical and/or systemic treatments, such as calcipotriene and tazarotene, can be used in conjunction with UVB, enhancing efficacy. However, this should be done with caution, as some can increase photosensitivity and increase risks of burning. Often, UV therapy can enable patients to reduce systemic treatment (National Psoriasis Foundation, 2016).

Figure 2.What is the difference between UVA and UVB wavelengths?

wavelength (nm)

UltravioletVisib

le

Infra

red

UVC UVB UVA

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Additional exposure to natural sunlight can result in burning the skin. Covering skin from natural sunlight, including hands and face is essential. Sunglasses should be worn immediately on injesting the tablets and until dark. The phototherapy team should check that the sunglasses worn are suitable for UV protection. The main side-effects reported with systemic PUVA are nausea, increased itch and redness of the skin. Advising patients to drink milk or ginger ale can help ease the nausea. To help settle itch, baths with colloidal oatmeal products or application of topical products can be advised (DermNet NZ, 2007; BAD, 2015).

Systemic PUVA can be more suitable for people who are unable to get in/out of a bath, have time restraints and if faces require treatment. PUVA is not recommended for those with other conditions, such as xeroderma pigmentosum, lupus erythematosus or if they have had skin cancer, (BAD, 2015; Menter et al, 2010).

Psoralen bath or soaks and UVASoaks are beneficial for patients that work outdoors, under fluorescent lighting, or suffer with nausea with psoralen tablets.

The skin is sensitised in water that is measured and set at a specific temperature for the psoralen to be effective. Timing is set for the duration of the soak. The skin is then patted dry and exposed to the UVA. Protection still needs to be considered, but the photosensitivity does disperse off the skin. A shower or washing hands/feet can help eliminate the photosensitivity effects following treatment.

TREATMENT

When treating the whole body, protection will be required in the machine regardless of the type of treatment (BAD, 2015). Unless directed, patients enter the cabinet undressed, and should be advised to wear goggles, or a face shield if the face is not needing treatment, and gentleman are asked to protect their genitalia by tucking it in a dark sock. This can protect from burning and risk of testicular cancer formation. Sun block to lips may be necessary if the patient is prone to developing cold sores.

Patients are advised to inform healthcare professionals of any changes in medication and/or problems with their skin following previous treatments, to attend regularly, to avoid natural sunshine and products such as protopics during their course of treatment. Patients should also be counselled about the short- and long-term risks of phototherapy before starting treatment (Menter et al, 2010), and complete written consents,

witnessed by the consenting doctor (Moseley et al, 2015). Sometimes, systemic treatments are used alongside phototherapy for increased efficacy.

It is important that an informed consent is carried out so that patients are aware of the responsibility that comes with this treatment. In the author’s clinical experience, the main difficulty for patients is the time needed for treatment, as phototherapy generally requires 2–3 treatments per week. Thus, work and school schedules need to be considered along with travel time, parking, and the treatment time, which, for some, is just not possible. Regular attendance enables the doses to be increased, and thereby more effective.

Can sunbeds be used instead?Phototherapy is provided by trained staff who are able to assess the skin and increase or decrease doses accordingly. The use of sunbeds can be dangerous, especially if combined with psoralen, which would result in severe burning and even death (Young et al, 2017). Sunbeds are not deemed safe. They are primarily UVA (95%), with a combination of UVB (5%). It has been reported that sunbed lamps emit stronger doses than that of tropical sunshine (Oliver, 2007). There is much evidence available to show that UV is connected with the development of skin cancer, (International Agency for Research on Cancer [IARC], 2007). The British

Table 1: Side-effects of narrowband UVB/TL01

Short-term risks Management Long-term risks ManagementBurning, redness (erythema) or tender skin – similar to sunburn

This usually occurs 12–24 hours after treatment

A gentle response to the light is good

Changes must be reported to the healthcare professional

Avoid additional sunshine or UV contact

Ageing of skin The British Photodermatology Group have issued guidelines as to the total number of UV treatments an individual can have in a lifetime

Itch Skin dries out with UV, apply moisturiser regularly

Increase fluid intakeAvoid long hot baths/showers Report if itch gets worse

Increased risk of certain cancers Mole check assessments carried out before treatment begins

Red Flag Risks

Burns, increased ageing, and increased risk of skin cancer over time are all significant risks with any type of phototherapy.

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NICE, London. Available online: http://pathways.nice.org.uk/pathways/psoriasis

Oakley A (2008) Treatment of psoriasis in pregnancy. DermNet NZ. Available online: www.dermnetnz.org/topics/treatment-of-psoriasis-in-pregnancy/ (accessed 21 March, 2018)

Oakley A (2015) Narrowband UVB phototherapy. Available online: www.dermnetnz.org/topics/narrowband-uvb-phototherapy/

Oliver H, Ferguson J, Moseley H (2007)Quantiative risk assessment of sunbeds; impact if new high power lamps. Br J Dermatol 350–6

Patricia SK, Clarissa CF, Lucas SCN, Licia MHM (2015) Treatment of psoriasis and psoriatic arthritis during pregnancy and breastfeeding. Ann Bras Dermatol367–75

Psoriasis and Psoriatic Arthritis Association (2016) Psoriasis and phototherapy patient information leaflet. Available online: www.papaa.org/sites/default/files/ps%20and%20phototherapy%20final.pdf

Psoriasis and Psoriatic Arthritis Association (2016b) Psoriasis and phototherapy. Available online: www.papaa.org/further-information/psoriasis-and-phototherapy

Skin Cancer Foundation (2013) UVA and UVB. Available online: www.skincancer.org/prevention/uva-and-uvb

Young M, Aldredge L, Parker P (2017)Psoriasis for the primary care practitioner. J Am Assoc Nurse Practitioners 29: 157–78

Association of Dermatologists issued a statement on their position to minimise the use of sunbeds to reduce risks of skin cancer.

CONCLUSION

Phototherapy in either form should be seen as a prescription provided by a dermatology specialist. It is an effective form of treatment for many and can be used again in the future. Most departments will not consider offering a further course for another year, due to the risk factors involved. If psoriasis creeps back rapidly, it may be considered ineffective. The treatment is personalised to the patient’s requirements, with positions in the cabinet being adapted to clear the skin as best as possible.

By having a full understanding of phototherapy and the commitment required to undertake a course of treatment, community nurses can educate patients of the benefits and prepare them for what is involved.

REFERENCES

Asztalos ML, Heller MM, Lee ES, Koo J (2012) The impact of emollients on phototherapy: a review. J Am Acad Dermatol 817–24

British Association of Dermatologists (2015) Phototherapy, Patient Information

Leaflet. updated June 2015. Available online: www.bad.org.uk/shared/get-file.ashx?id=175&itemtype=document

British Association of Dermatologists.Sunbeds. Available online: www.bad.org

DermNet NZ (2007) UVB phototherapy CME: Phototherapy. Available online: www.dermnetnz.org/cme/phototherapy/uvb-phototherapy/ (accessed 24 March, 2018)

Honigsmann H (2013) History of phototherapy in dermatology (Perspective). Photochem Photobiol Sci 12:16–21

International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer (2007) The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systemic review. Int J Cancer 120: 1116–22

Jackson K (2012) We still need to do more for psoriasis patients. Dermatological Nurs

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Juzieniene A, Grigalivicus M, Juraleviciute M, Grant WB (2016) Phototherapy and vitamin D. Clin Dermatol 548–55

Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, et al (2010) Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 5: Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. JAm Acad Dermatol 62(1): 114–35

Monem El, Mofty A (1948) A preliminary clinical report on the treatment of leucodermia with Ammi majus Linn. JEgypt Med Assoc 651–5

Moseley H, Allan D, Amatiello H, et al (2015) Guidelines on the measurement of ultraviolet radiation levels in ultraviolet phototherapy: report issued by the British Association of Dermatologists and British Photodermatology Group 2015. Br J Dermatol 333–50

National Psoriasis Foundation (2016)Phototherapy. Available online: www.psoriasis.org/about-psoriasis/treatments/phototherapy

National Institute for Health and Care Excellence (updated Sept 2017) Psoriasis:assessment and management [CG153]. NICE, London. Available online: www.nice.org.uk/Guidance/CG153 (accessed 21 March, 2018)

National Institute for Health and Care Excellence (2018) Psoriasis overview.

KEY POINTSSunshine has been used to treat the skin for many years.

Light therapy involves exposing the skin to wavelengths of ultraviolet (UV) light under medical supervision. Only the UVA and UVB spectrum is of value to treat skin conditions.

It is important that an informed consent is carried out so that patients are aware of the responsibility and risks that come with this treatment.

Sometimes, systemic treatments are used alongside phototherapy for increased efficacy.

Having read this article,

Your knowledge of the NICE treatment pathway for psoriasis

The risks of phototherapy

The advice you would give patients who are about to start a course of phototherapy treatment.

Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation

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