Ultraviolet Light Treatment

Definition

Ultraviolet light treatment uses a particular band of the nonvisible light spectrum to treat psoriasis and a variety of other skin diseases. It can be used alone or in combination with other medications applied directly to the skin or taken internally.

Purpose

Ultraviolet (UV) light treatment is used primarily in cases of severe psoriasis that have not responded to other medications or in cases affecting large portions of the body. Patients will typically receive a series of 3-5 weekly treatments for a month or more to bring their psoriasis symptoms into check. They may also receive periodic maintenance treatments to prevent recurrence of their psoriasis. Other skin conditions treated with UV light treatments are vitiligo, a condition in which people lose pigmentation in large patches of their skin, and atopic dermatitis, an allergy-related skin condition that produces itchy, reddish, and scaly patches of skin.

Precautions

Exposure to UV radiation is known to prematurely age the skin over time and increase the risk of skin cancer. These potential effects should be weighed against the potential benefits of the treatment. A history will be taken regarding sun exposure and burning, medications, such as diuretics, that may increase UV sensitivity exposure, and any history of skin cancers. Sometimes, UV light treatments are given in combination with photosensitizing agents, which maximize UV's effects on the skin. Patients who receive these agents, called psoralens, must take care to avoid exposure to sunlight, which also contains UV radiation. Exposure to UV radiation can also cause cataracts and other eye damage, so the patient's eyes must be adequately shielded during the treatments.

Description

UV light treatment can employ one of two bands of the ultraviolet spectrum: ultraviolet A (UVA), and ultraviolet B (UVB). Patients receive full-body treatments in special light boxes; smaller areas of the skin are sometimes treated with hand-held devices.

UVB treatment

Psoriasis is the most common skin disease treated with UVB light treatment. Its mechanism of action remains unclear, but investigators speculate it may kill abnormal skin cells or alter immune system reactions in the skin. Most patients require 18-30 treatments before substantial improvement or complete clearing is seen. The intensity of the UV applied will vary depending on the patient's skin type. Fair-skinned patients will start with a relatively weaker dose; dark-skinned patients, a stronger dose. Physicians will first expose a small area of skin to UVB to determine the minimum erythema dose (MED), the minimum amount of UVB that produces redness 24 hours after exposure. Patients will be exposed for short times early in the treatment cycle, but these times will gradually increase over time.

The Goeckerman regimen, a treatment that combines UVB light with coal tar applied to the skin, is among the oldest and most frequently used treatments for patients with moderate to severe psoriasis. The coal tar is a photosensitizing agent, and, when it interacts with UVB, it appears to limit the abnormal turnover of skin cells characteristic of psoriasis. Although treatments with UVB and coal tar are highly effective, many patients dislike the smell. Some investigators believe that the use of petroleum jelly or other emollients is just as effective as the coal tar preparations.

In addition to their UVB treatments, many patients will receive such systemic agents as methotrexate, a drug used in severe case of psoriasis, and certain vitamin A derivatives called retinoids. A newer retinoid called bexarotene (Targretin), which was originally developed to treat cutaneous T-cell lymphoma, shows promise as a treatment for psoriasis in combination with UVB therapy.

Another new development in UV therapy is the use of a laser as the source of the UVB radiation. The type of laser that is used is known as a 308-nm excimer laser, which uses a specific mixture of gases to produce high-intensity, short pulses of UV light.

PUVA treatment

Psoralens are photosensitizing agents found in plants. They have been known since ancient Egypt but have only been available in a chemically synthesized form since the 1970s. Psoralens are taken systemically or can be applied directly to the skin. The psoralens allow a relatively lower dose of UVA to be used. When they are combined with exposure to UVA in PUVA, they are highly effective at clearing psoriasis. Like UVB light treatments, the reason remains unclear, though investigators speculate there may be similar effects on cell turnover and the skin's immune response.

Choosing the proper dose for PUVA is similar to the procedure followed with UVB. The physician can choose a dose based on the patient's skin type. Often, however, a small area of the patient's skin will be exposed to UVA after ingestion of a psoralen. The dose of UVA that produces uniform redness 72 hours later, called the minimum phototoxic dose (MPD), becomes the starting dose for treatment.

Some patients experience nausea and itching after ingesting the psoralen compound. For these patients "bath PUVA" may be a good option.

Preparation

No major preparation is required for UV light treatments. Areas of the skin that are especially sensitive to the effects of UV light, such as the groin, backside, or face, are shielded during the treatments. Areas not affected by psoriasis are also covered. Special goggles are worn to protect the eyes. Some physicians apply an emollient, such as petroleum jelly, to the skin or other topical agents, such as coal tar, to enhance the results. In PUVA treatments, the psoralen is usually taken one hour before the treatment.

Aftercare

No major aftercare is required following UV light treatments. Patients, however, must take great care to limit or eliminate other exposures to UV radiation, such as from sunlight or tanning beds, because of the increased risk of premature aging of the skin and the development of skin cancers. Patients should monitor their skin closely for any signs of precancerous or cancerous skin growths in the future.

Risks

People who receive UV light treatments are at higher risk of premature aging of the skin, and of developing skin cancer. These risks should be balanced against the benefits of treatment. Patients must also take care to limit or eliminate their exposure to other sources of UV radiation, especially if they are taking a psoralen compound in addition to receiving the UV treatments.

Normal results

Psoriasis will normally show significant improvement to complete healing with three to five UVB treatments a week for about four to five weeks. PUVA treatments may require a bit longer to take effect, but because the overall dosage of UV is lower, they are thought by some investigators to be a safer alternative to UVB treatments.

Abnormal results

Modern light boxes carefully control the dosage of UV radiation and the exposure time. Overdose or overexposure is possible, however, and can lead to severe burns. It is important to choose a treatment provider who is experienced in the technique. It is also important to tell the physician about all medications being taken by the patient. Some medications, either alone or in combination with a psoralen, can provoke an extreme reaction to UV radiation. One medication that has been shown to be helpful in treating burns caused by overexposure to UV radiation is a gel containing a platelet-activating antagonist factor, or PAF, known as WEB 2086.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Psoriasis." Section 10, Chapter 117 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Baltas, E., V. Trach, A. Dobozy, and L. Kemeny. "Platelet-Activating Factor Antagonist WEB 2086 Inhibits Ultraviolet-B Radiation-Induced Dermatitis in the Human Skin." Skin Pharmacology and Applied Skin Physiology 16 (July-August 2003): 259-262.

Bianchi, B., P. Capolmi, L. Mavilia, et al. "Monochromatic Excimer Light (308 nm): An Immunohistochemical Study of Cutaneous T Cells and Apoptosis-Related Molecules in Psoriasis." Journal of the European Academy of Dermatology and Venereology 17 (July 2003): 408-413.

Smit, J. V., E. M. De Jong, and P. C. Van De Kerkhof. "Effects of Oral Bexarotene (Targretin) on the Minimal Erythema Dose for Broad-Spectrum UVB Light." Skin Pharmacology and Applied Skin Physiology 16 (July-August 2003): 237-241.

ORGANIZATIONS

American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. 〈http://www.aad.org〉.

National Psoriasis Foundation. 6600 SW 92nd Ave., Suite 300, Portland OR 97223-7195. (503) 244-7404. 〈http://www.psoriasis.org〉.

KEY TERMS

Erythema— The medical term for redness of the skin produced by congestion of the capillaries in the skin.

Goeckerman regimen— UVB light therapy combined with topical coal-tar preparations.

Minimum erythema dose— The minimum amount of UVB that produces redness 24 hours after exposure. It is the starting dose for UVB light treatments.

Minimum phototoxic dose— The dose of UVA that produces uniform redness 72 hours after ingesting a psoralen compound. It becomes the starting dose for PUVA treatment.

Psoralen— A family of photosensitizing chemicals that can be found in lemons, celery, and other plants. Chemically synthesized versions are used to augment the effects of UVA light treatments.

PUVA treatments— Treatments with the photosensitizers called psoralens and UVA.

Ultraviolet light— A portion of the light spectrum not visible to the eye. Two bands of the UV spectrum, UVA and UVB, are used to treat psoriasis and other skin diseases.