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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.3 Rio de Janeiro July 2009
Ida DuarteI; José Antonio Jabur da CunhaII; Roberta Buense BedrikowIII; Rosana LazzariniIV
IPh.D., Professor, Medical School,
Santa Casa de Sao Paulo. Responsible for the sector of Allergy and Phototherapy
of the Dermatology Clinic, Santa Casa de Sao Paulo Sao Paulo (SP), Brazil
IISpecialization under course, Department of Dermatology, Santa Casa de Sao Paulo Sao Paulo (SP), Brazil
IIIAssistant Physician, Dermatology Clinic, Santa Casa de Sao Paulo Sao Paulo (SP), Brazil
IV Head of the Dermatology Clinic, Santa Casa de Sao Paulo Sao Paulo (SP), Brazil
BACKGROUND: Moderate and severe forms of psoriasis require phototherapy
and / or systemic medications. Both UVA and UVB can be used to treat cases of
moderate and severe psoriasis, and the effectiveness of both has been proven.
OBJECTIVE: to access the prescription behavior relating to two types of phototherapy for treating psoriasis refractory to topical treatment: narrowband UVB (NB-UVB) or psoralen plus UVA phototherapy (PUVA).
METHODS: Between January 2006 and December 2007, patients referred to two phototherapy services were included in this study. Data on the cases and on the type of prescription were collected retrospectively.
RESULTS: Among the 67 studied patients, 51 (76%) were treated with narrowband UVB. The reasons for the indication were the presence of the guttate type of psoriasis (22%), the presence of thin plaques (15%), the use of drugs that affected photosensitivity (15%), age less than 20 years (9%), skin type I (9%), and liver disease (6%). The remaining 16 (24%) were treated with PUVA. The main indication for this therapy was the severity of the disease (15%), followed by the presence of skin type IV (9%).
CONCLUSIONS: Prescriptions of narrowband UVB exceeded those of PUVA because of fewer contraindications and fewer possible side effects, and because it was a more practical option.
Keywords: Phototherapy; Psoriasis; Ultraviolet Rays; Puva Therapy
Psoriasis is a chronic inflammatory recurrent disease, with variable clinical manifestations and severity. It is characterized mainly by erythema, infiltration and skin desquamation. It is estimated that 2% to 3% of the world population is affected by the disease 1-3.
Topical therapies are normally enough to control mild psoriasis, but moderate and severe forms require other therapeutic options, such as phototherapy and systemic medication 4-6.
UV light has antiinflammatory anti-proliferative and immunosuppressant properties 7,8. UV radiation is divided into UVA (440-320nm), capable of reaching the epidermis and deep dermis, UVB (320-290nm), which reaches only the epidermis, and UVC (290-200nm), that does not reach the surface. UVA rays are subdivided into UVA I (400 340nm) and UVA II (340 320nm), and UVB band of 311 312nm is named Narrow Band UVB NB-UVB). The use of this type of UVB in treating psoriasis started in the 80s when the first UVB bulbs were developed (Philips, Eindhoven, The Netherlands). 7,9 Therefore, this method proved to be effective in the control of psoriasis using suberythematogenic doses 10. Studies have shown that NB-UVB may be more effective than broad band UVB in treating psoriasis 9,10, consequently, the choice is currently made between UVA and NB-UVB.
Both NB-UVB and PUVA may be used to treat moderate and severe forms of psoriasis, and its effectiveness had been confirmed for both therapies 6,11,12. Thus, the option for one or other phototherapy modality should be based in other factors in addition to efficacy, including safety, previous response to treatment, psoriasis severity and treatment compliance 6.
The purpose of the present study was to assess the frequency with which PUVA and NB-UVB are prescribed among patients with diagnosis of psoriasis that had not responded to topical treatment.
MATERIAL AND METHOD
Between January 2006 and December 2007, patients refractory to topical treatment were referred to two centers of phototherapy (a university hospital and a private clinic, both with the same medical team, the same treatment protocol and the same equipment) and included in this retrospective study. All patients had indication to NB-UVB and PUVA.
The study excluded subjects who had been taking combined therapy (topical and/or systemic) or any other systemic medication to psoriasis up to two months before the beginning of phototherapy.
Demographical data were retrospectively collected from medical charts of patients under phototherapy. We also collected data about the type of skin (according to Fitzpatrick classification 13), type of psoriasis (vulgaris, guttate or erythrodermic) 14, disease severity, type of prescribed phototherapy (PUVA or NB-UVB) and clinical progression.
The main reasons for choosing the phototherapy regimen were recorded in medical charts and based on patients age, skin phototype, disease severity, comorbidities and use of systemic drugs. The criteria used in the phototherapy services were: NB-UVB as first choice in subjects aged less than 20 years, in people with guttate psoriasis or thin plaques, and in cases with mild to moderate severity. PUVA phototherapy was the first option in extreme cases with thick plaques and skin types IV or VI. PUVA was contraindicated in patients with liver impairment or using photosensitizing drugs; in these cases, severity or skin phototype were not considered and NB-UVB was indicated.
All patients were submitted to phototherapy, with two sessions per week, using professional equipment (Prolumina Fototerapia, Sao Paulo, Brazil: cabin UVA with 48 Philips Sunlamp 100W-R bulbs or cabin NB-UVB with 42 narrow band bulbs Philips TL 100W/01).
Sixty-seven patients were treated during the study period: 37 men (55.2%) and 30 women (44.8%), ages ranging from 12 to 87 years, average of 39 years of age. Six of them (9%) were classified as type I Fitzpatrick, 35 (52.2%) as type II, 15 (22.4%) as type III, and 11 (16.4%) as type IV.
Only one patient (1.5%) presented erythrodermic psoriasis, whereas 16 (24%) had guttate psoriasis and 50 (74.5%) had psoriasis vulgaris of variable severity.
Among 67 studied patients, 51 (76%) were treated with NB-UVB. Reasons for indicating NB-UVB are listed in Table 1 and were distributed as follows: presence of guttate psoriasis (22%), presence of thin plaques (15%), use of drugs that interfered in photosensitivity (15%), age below 20 years (9%), phototype I (9%), and presence of associated hepatopathy (6%). The 16 remaining (24%) were treated with PUVA. The main indication of this type of therapy (Table 2) was severity of the disease (10 patients, 15%), followed by the presence of skin type IV (6 patients, 9%). Figure 1 illustrates the prescription of phototherapy in assessed patients.
Many studies have compared the efficacy of therapies NB-UVB and PUVA in moderate to severe psoriasis 15-17. The considerable heterogeneity between the studies concerning disease severity, psoriasis subtype, cutaneous phototype, phototherapy regimens and methods used to measure the results, hinders the conduction of a consistent systemic review. Even though PUVA has been reported as more effective than NB-UVB in the control of psoriasis 4,6,9, a standardized therapeutic approach to all cases of moderate to severe psoriasis has not been established 4,6.
As known, psoriasis is a globally distributed disease that affects both genders and broad age range 1,2. In the studied sample, there was homogeneity of gender distribution, at the same time the age of patients treated with phototherapy was very broad, from the 2nd to the 9th decade of life. Age and gender are not limiting factors for the indication of phototherapy 15.
In our services of phototherapy NB-UVB was more frequently indicated that PUVA (76% and 24%, respectively) for treatment of psoriasis. It was observed that many patients with psoriasis presented other comorbidities that contraindicated the treatment with PUVA. Patients with liver impairment or using drugs to treat hypertension, diabetes or use of antiinflammatory had indication to NB-UVB primarily owing to safety 15,17, considering that some drugs may enhance the individual sensitivity to UV rays. This was the case of 28% of the patients treated in our sample: in 19% NB-UVB was prescribed owing to the use of photosensitizing drugs and in 9% owing to liver disease.
In young patients, NB-UVB is indicated because it represents lower risk of inducing skin cancer in the long run 6,18. In the studied group, 12% of the patients had as their first choice NB-UVB because they were younger than 20 years. It is important to consider the risk of cancer as a result of accumulative exposure to UV radiation, associated with high life expectancy of these patients.
In addition to these aspects, NB-UVB is more frequently indicated than PUVA owing to the practicality of the application 6. The possibility of using this phototherapy in the absence of previous prescription of psoriasis drugs makes it easier for patients to accept it, given that these drugs many times cause nausea and other adverse effects. The use of other medications may be maintained during treatment with NB-UVB. Among the assessed patients, PUVA was the most indicated to patients with thick plaques and skin types IV and VI (Fitzpatricks classification).
Even though the purpose of this study was not to assess therapeutic effectiveness but rather to understand how prescription of phototherapy is made in psoriasis, it was possible to observe that both therapies are effective. The mean baseline PASI in patients treated with PUVA was 14.9 and in the group treated with NB-UVB it was 10.4. Among the treated patients with PUVA, PASI 75 index was obtained in 75% of the cases, and good results were also obtained in 80.4% of the patients treated with NB-UVB. The difference between the groups was not statistically significant (p<0.05).
NB-UVB prescriptions exceeded those of PUVA owing to the lowest number of contraindications and lower likelihood of adverse events, and because it is a more practical option. Given that both PUVA and NB-UVB proved to be effective in the control of psoriasis, the option for each treatment should take into account the severity of the disease, type of skin, use of medication and patient characteristics. Individualized clinical assessment should guide the indication between one or the other type of phototherapy.
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Conflict of interest:
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How to cite this article: Duarte I, Cunha JAJ, Bedrikow RB, Lazzarini R. Qual é o tipo de fototerapia mais comumente indicada no tratamento da psoríase? UVB banda estreita e PUVA: comportamento da prescrição. An Bras Dermatol. 2009;84(3):244-48.