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PHOTOTHERAPY UPDATE 2009 Frederick C. Fehl, III MD Dept of Dermatology SCPMG San Diego.

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Presentation on theme: "PHOTOTHERAPY UPDATE 2009 Frederick C. Fehl, III MD Dept of Dermatology SCPMG San Diego."— Presentation transcript:

1 PHOTOTHERAPY UPDATE 2009 Frederick C. Fehl, III MD Dept of Dermatology SCPMG San Diego

2 Disclosures I have no known conflicts with any of the products, medications or devices, discussed in this lecture I am receiving no honoraria

3 Figure shows electromagnetic spectrum divided into the major regions: UVA (UVA I and UVA II ) UVB UVC The Electromagnetic spectrum

4 UV Spectrum UVC ( nm) –An arbitrary division was made between UVB and UVC at 290nm because wavelengths shorter then 290nm do not reach the earths surface –Absorbed by the ozone layer –These wavelengths are absorbed by DNA, RNA and proteins of cells and can be lethal to organisms –Hence the term germicidal radiation –Used in germicidal lamps that emit 254nm

5 UV Spectrum UVB ( nm) –S–S–S–Strongly erythemogenic (sunburn rays) –O–O–O–Ordinary window glass filters out wavelengths shorter then 320nm –T–T–T–There is great variation of the erythemogenic potential within the range: For example 297nm is nearly 100 times more erythemogenic then 313nm radiation even though they are both in the UVB spectrum

6 UVA ( nm) –Divided into two groups: UVA1 ( nm) and UVA2 ( nm) –aka as tanning rays (tanning parlors emit) –Not blocked by window glass unless… –UVA radiation is more deeply penetrating (penetrates to the deeper dermis whereas UVB is absorbed by the epidermis –This is why I often refer to it as the wrinkle rays

7 UV FACTS Ultraviolet light is light we can not see…its radiation! Comprises 5% of terrestrial radiation It spans the region of light from 400 to 100nm UV is 7% more intense in the Southern Hemisphere summer than Northern Hemisphere summer UVB comprises 5% of total UV compared to 95% for UVA…but UVB is more biologically active!

8 UV FACTS On a cloudy day…66% of UV gets to ground (75% in the tropics) In the tropics….a cloudy day get 75% to ground Reflection off the ground is less than 10% except for snow which can reflect 90%! Choppy water more reflective than calm water For every 1,000 feet in elevation, there can be 7% more UV What about the Ozone depletion?

9 Red States vs. Blue States Summary 2008 Election Results Their may be more ozone depletion in Blue States then Red States Bush, Limbaugh et al

10 UV FACTS UVB inflammation is a delayed effect: –Develops 1-5 hrs after high dose –Max effect at 24 hrs –fades in 3 days UVA inflammation is immediate (immediate pigment darkening) The UVA tan offers little protection compared to UVB UVA penetrates deep to dermis…UVB affects epidermis

11 UV FACTS UVB is considered more carcinogenic: AK, SCC and BCCs UVA does have detrimental clinical effects ( e.g., flares autoimmune skin diseases such as lupus etc, has been linked to melanoma) UV can be our friend…Vitamin D, mood elevation UV is immunosuppressive! 70% of UV damage occurs before age 20!

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13 Historical Aspects: Phototherapy – Ancient times: Topical exposure to plants containing psoralens + natural sunlight used in Egypt and India to treat vitiligo –1925: Use of crude coal tar and UV radiation was introduced by Goeckerman (Mayo Clinic); became the standard therapy for psoriasis for the next 50 years –1974: PUVA developed (oral regimen) PUVA was quite effective for severe psoriasis –1970s: broadband UVB also introduced BB UVB IF given in doses that produce a slight erythema could clear mild psoriasis

14 Mechanisms of Action of UVL Reduction in skin proliferation (1st way): –UVL is absorbed by chromophore –The most important chromophore for UVB is DNA –Pyrimidine dimers are formed –These toxic photoproducts reduce DNA synthesis Reduction in skin proliferation (2nd way): –UVL induces the expression of p53 tumor suppressor gene –p53 causes cell cycle arrest and/or apoptosis (cell death)

15 Mechanisms of Action of UVL Immunosuppressive effects: –Induces Interleukin 6 and 10 (sunburn sxs) –Langerhans cells (antigen presenting cells) are inhibited by UVL –Keratinocytes release IL-1 and 6, Prostaglandins E2 and TNF-α Secretion of these compounds alters the local immune response and may contribute to suppression of disease

16 Action Spectrum The effectiveness of clearing psoriasis plotted against wavelength is defined as the action spectrum of phototherapy It is most desirable to use wavelengths (λ) which are maximally therapeutic and minimally erythemogenic

17 Studies in the early 1980s demonstrated that 304 and 313nm had the optimal anti-psoriatic effect within the UVL spectrum: For wavelengths shorter then 295nm, no improvement in psoriasis occurred (remember shorter λs are more erythemogenic then therapeutic) 304nm 313nm Parrish, JA and Jaenicke, KF J Invest Dermatol 1981; 76: <295nm

18 Action Spectrum The Philips Corp armed with the knowledge regarding the action spectrum of psoriasis develops a fluorescent lamp, TL 01, that emits the optimal narrow band UVB frequency: nm

19 Differences: broadband and narrowband UVB NB UVB is much less erythemogenic then BB UVB –For example: 297nm is nearly 100 times more erythemogenic then 313nm radiation even though they are both in the UVB spectrum Shown to be as effective as PUVA in the treatment of psoriasis Theoretically safer then BB UVB or PUVA

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23 UVB Protocol

24 Pre-treatment Check List: UV Therapy Review the patients history (Snapshot)? –What disease is the MD treating? –Does the patient have co-morbidities that may make UV contraindicated?

25 Diseases Treated with UV Psoriasis, psoriasis, and mostly psoriasis Atopic Dermatitis PMLE Pruritus of renal failure Pruritus of liver Disease (e.g., PBC) Scleroderma Idiopathic Pruritus of unknown etiology CTCLVitiligo Eosinophilic folliculitis of HIV Winter Mood Affective Disorder

26 Pre-treatment Check List: UV Therapy Review the patients history (Snapshot)? –What disease is the MD treating? –Does the patient have co-morbidities that may make UV contraindicated?

27 UV AGRAVATED DISEASES PMLESLEDLESCLE Solar Urticaria Xeroderma Pigmentosa Chronic Actinic Dermatitis Cockaynes Syndrome, Blooms PCTDermatomyositisPemphigus Actinic Reticuloid Actinic LP

28 Pre-treatment Check List: UV Therapy Review the Medications List: –Are there any medications listed that are photosensitizing? –Will they be using any topical medications in conjunction with their UV therapy? DovonexVecticalTazorac –Are they taking any oral agents to facilitate their Rx? Acitretin, Isotretinoin

29 Medications known to cause photosensitivity Every light box facility should have a list such as this one to cross check medications prior to starting UVB Examples include: Zanolli et al textbook: Phototherapy Treatment Protocols (listed in KP protocol) Litts Drug Eruption Reference Manual will also list

30 Pre-treatment Check List: UV Therapy Labs: –Did the MD order any pre-treatment labs? Physical Exam: –Do you agree with the MDs Fitzpatrick skin type assessment? Orders: –Do the orders make sense! Right protocol for the disease c/w published protocols Broadband UVB vs. Narrow Band UVB

31 How do you do it? What mj do you start at? How much do you increase at each visit? What happens if you miss a day, a week or a month? What happens if the patient sunburns? Do you ask if the patient started any new meds?

32 Dosing determination for UVB Optimal done uses minimal erythema dose determination (MED) for individual patients by intricate phototesting Not typical used by most Dermatologists since it is time consuming and nurse intensive Most Dermatologists use schedules based on the patients skin type

33 Example of MED determination NB UVB

34 UVB Treatment Protocol Using MED

35 Fitzpatrick Skin Type Response to Sun ExposureExamples IAlways burns, never tansFair skin and freckles, blue eyed, Celts IIAlways sunburns, tans minimallyFair skin, blond hair, blue eyes, Scandinavian IIISometimes sunburns, tans moderatelyFair skin, brown hair, brown eyes, unexposed skin is white IVSeldom sunburns, tans easilyLight brown skin, dark hair, brown eyes, unexposed skin is tan; Mediterranean, Hispanic VRarely sunburn, tans profuselyBrown skin; Darker Mediterranean, some Asians, Pacific Islander, Indian subcontinent VINever sunburns, deeply pigmentedAfrican Americans

36 Fitzpatrick Skin Type? Fitzpatrick Skin Type I

37 Fitzpatrick Skin Type? Fitzpatrick Skin Type II

38 Fitzpatrick Skin Type? Fitzpatrick Skin Type III

39 Fitzpatrick Skin Type? Fitzpatrick Skin Type IV

40 Fitzpatrick Skin Type? Fitzpatrick Skin Type V & Type III

41 Fitzpatrick Skin Type? Fitzpatrick Skin Type VI

42 Initial NB UVB Dosing based on Fitzpatrick Skin Type Fitzpatrick Skin TypeTanning ResponseInitial NB UVB Dose IAlways burns, never tans100 mJ IIUsually burn, tans with difficulty 220 mJ IIISometimes mild burn, tan average 260 mJ IVRarely burns, tans with ease 330 mJ VVery rarely burns, tans very easily 350 mJ VINo burn, tans very easily400 mJ Kaiser Protocol dated 10/15/07

43 UVB Phototherapy for Psoriasis Ideally 3X a week (Dr. Koo recommends up to 5X a week) Combination therapy is ideal! Calicipotriene + UVB 2X/week = UVB 3X/week Tazarotene 3X/week added to UVB requires less than ¼ of UVB to achieve 50% PASI Goeckerman, Anthralin, Keratolytics

44 Current Kaiser Recommendations regarding Dose Escalation based on Skin Type for NB UVB Skin Type Interval Increase Estimated Dose GoalMaximum Dose (not to exceed) I15mJ520 mJ2000mJ II25mJ880 mJ2000mJ III40mJ1040 mJ3000mJ IV45mJ1320 mJ3000mJ V60mJ1400 mJ5000mJ VI65mJ1600 mJ5000mJ

45 Key Safety Points Type of box: –NB vs. BB –For clinics with multiple boxes even if same light system we assign a pt to a particular box we assign a pt to a particular box they always use that box even if they have to wait! Remember units matter: –800 milljoules vs. 800 Joules …….Burn Unit!!!

46 Two different boxes with two different input metrics

47 Not all UV light is Equal

48 Key Safety Points Physicians should order the UVB in Health Connect using the units that you will enter into the box (i.e., avoid unit conversion issues: how many millijoules = a joule?)

49 my order I then add my smartphrase.FFUVB These units should correspond to what YOU input into that pts light box

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54 NB UVB Protocols Remember different diseases use different protocols –Vitiligo protocol quite different then psoriasis –Atopic dermatitis protocol different then psoriasis (e.g., much lower max dose) Remember the Kaiser Permanente protocol is a quite conservative NB UVB protocol for the treatment of psoriasis imho Remember the Kaiser Permanente protocol is a quite conservative NB UVB protocol for the treatment of psoriasis imho When in doubt whether the protocol is appropriate for the disease being treated ask the ordering MD to verify!

55 Thank You!

56 Vitiligo NB UVB Protocol Treatment frequency is typically twice weekly Start at all patients at 200 mJ/ cm 2 Incremental Dosing –If skin was pink the previous night and: Pink now: Skip treatment & notify the MD Not Pink now: Treat at same dose –If skin was not pink the previous night: Increase by 50 mJ/cm 2 Maximum dose is mJ /cm 2 Missed Treatments of NBUVB for Vitiligo: 4-7 days100% (same as last dose) 8-14 daysdecrease dose by 50% daysstart over

57 © 2003 Elsevier - Bolognia, Jorizzo and Rapini: Dermatology - Fig Narrowband phototherapy for vitiligo. Before treatmentafter 10 mos of NB UVB twice weekly

58 Whats New in Phototherapy Narrow Band UVB 311 UVA – 1 Photodynamic Therapy –Blue Light –Red Light Excimer Laser New Lasers

59 UV FACTS UV is a discrete, oscillating electromagnetic pulse of energy, E (joules, J) and a wavelength, lambda (nanometres, nm, th m), travelling through space at velocity, c (3x10 8 th m/s), such that E=hc/lambda, where h= 6.63 X th J/s (Plancks Constanat).

60 Common Terms Watt (W) = Unit of power Energy (Joules) = Power (W) x time (sec) –Joule (J) = Unit of energy –1000 Millijoules (mJ) = 1 Joule Fluence (Dose) = Energy delivered to a unit area (J/cm 2 ) Irradiance = Power delivered to a unit area (W/m 2 )


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