How this underused treatment can help
Phototherapy is the original psoriasis treatment. For as long as people have had the disease, they've treated it with sunlight. Even today, with all the high-tech remedies available, light therapy continues to be one of the most effective treatments for psoriasis, an autoimmune disorder that causes skin cells to grow too rapidly, resulting in red, itchy lesions on the surface of the skin.
“When ultraviolet light hits skin, it does all kinds of things,” says Steven Feldman, MD, PhD, a professor of dermatology at the Wake Forest University School of Medicine in Winston-Salem, N.C. Ultraviolet light kills the immune cells in the skin that contribute to psoriasis, and research suggests that UV light may also disrupt the faulty signals between immune cells and skin cells that lead to psoriasis lesions.
With relatively few side effects, phototherapy is an effectiveyet underusedtreatment, experts say. “Phototherapy is a great treatment to start with,” says Kathy Kavlick, RN, community outreach nurse for the Murdough Family Center for Psoriasis in Cleveland. “Some people get really good results from it.”
Types of phototherapy
Phototherapy is usually administered on an outpatient basis in a dermatologists office two to three times a week, using a walk-in light booth that looks like a tanning bed stood on end. Light boxes for home use are also available.
There are two main types of phototherapy:
- Ultraviolet B light (UVB), one of the components of sunlight, is especially effective for treating psoriasis. During the treatment patients are exposed to the light for just a few seconds at first, and the exposure time is gradually increased to several minutes per treatment. UVB treatment is sometimes administered with topical treatments such as coal tar, anthralin, or just mineral oil. A form of UVB light known as narrow-band (NB-UVB) has been shown to be even more effective than UVB, and is increasingly being used by dermatologists.
- Although not as potent as UVB, ultraviolet A light (UVA) is also used to treat psoriasis. UVA treatment generally takes longer than UVBexposure times can reach 15 to 20 minutesbut at these higher doses it is also effective in clearing lesions. UVA light is often combined with an oral medication known as psoralen (a treatment known as PUVA).
A newer variation of phototherapy uses excimer or pulsed-dye lasers to target individual plaques. Research suggests that laser therapy may require fewer treatments and produce longer remissions, but since this technique is so focused it is not very practical for people with widespread lesions. As Dr. Feldman notes, however, roughly eight out of 10 people with psoriasis have lesions only in small, isolated spots, and laser therapy may grow more popular as the technology becomes faster and more effective.
What works best
Patients generally require about 20 phototherapy sessions before they see an improvement in their skin. Although response rates vary, studies suggest that 65% of the patients who receive UVB treatment and 75% of the patients who receive NB-UVB will experience significant skin clearance. Although UVB treatments are more widely used, PUVA may actually be more effective.
In a 2006 study in the Archives of Dermatology that compared PUVA and NB-UVB therapy in patients with chronic plaque psoriasis, the patients who underwent PUVA therapy had a significantly higher clearance rate (84%) than those who received NB-UVB (65%). The former group also required fewer treatment sessions, and the effects lasted longer.
PUVA does have some potentially serious side effects, however. Nearly one-third of patients experience nausea after treatmentand, more important, PUVA carries a long-term risk of skin cancer, especially in patients with fair skin.
The psoralen molecule used in PUVA is believed to be largely responsible for the increased risk. Psoralen, which is ingested orally or applied topically, enters the bodys cells and, when activated by UV light, changes their DNA. This process kills off immune cells close to the skin and helps control psoriasis, but it also leads to collateral damage that can cause skin cancer in the long run.
Because of the risk of skin cancer, PUVA is typically reserved for the most severe and stubborn psoriasis cases. “PUVA is a very, very effective treatment,” says Dr. Feldman. “Its at least as effective as narrowband UVB, but it causes an increased risk of skin cancer, so we tend to avoid using it.”
UVB light is known to cause skin cancer as well, but studies have not shown any increased risk of skin cancer among psoriasis patients who have undergone UVB phototherapy.
If its so effective, why isn't phototherapy used more?
Although phototherapy is considered a first-line treatment for psoriasis, patients and dermatologists alike report that it is often impractical.
Convenience is a factor, since patients need to visit their doctors office several times a week during business hours. But it can also be expensive; for each treatment, most insurance companies charge an office-visit co-pay, which tends to be higher than drug co-pays.
The National Psoriasis Foundation, the American Academy of Dermatology, the United States Department of Health and Human Services, and the World Health Organization all discourage the use of commercial tanning beds for treating psoriasis. "The spectra of light in tanning beds vary greatly and often include wavelengths of light that are carcinogenic and photo-damaging," reads a 2013 statement from the National Psoriasis Foundation. "The ultraviolet radiation from these devices can damage the skin, cause premature aging and increase the risk of skin cancer."
Good old sun
As people have known for thousands of years, natural sunlight is an effective treatment for psoriasis, although the effects may take several weeks to materialize. To avoid sunburn and overexposure, the National Psoriasis Foundation recommends only sunbathing after discussing it with your doctor. Your doc will likely prescribe multiple short sunbathing sessions. (Sunburns can actually exacerbate psoriasis.) Some doctors recommend going into the sun for a few minutes without sunscreen, and then applying at least SPF 15.