1. Frederick C. Fehl, III MD Dept of Dermatology SCPMG San Diego
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. The Electromagnetic spectrum
Figure shows electromagnetic spectrum divided into the major regions:
UVA (UVA I and UVA II )
UVB
UVC

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 earth’s 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 (280-320nm) Strongly erythemogenic (sunburn rays)
Ordinary window glass filters out wavelengths shorter then 320nm
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. UV Spectrum
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…it’s 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. “Their may be more ozone depletion in Blue States then Red States”
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 BCC’s
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!

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
1970’s: 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. Action Spectrum
Studies in the early 1980’s 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 λ’s are more erythemogenic then therapeutic)
304nm
313nm
<295nm
Parrish, JA and Jaenicke, KF J Invest Dermatol 1981; 76:

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

23. UVB Protocol

24. Pre-treatment Check List: UV Therapy
Review the patient’s 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
CTCL
Vitiligo
Eosinophilic folliculitis of HIV
Winter Mood Affective Disorder

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

27. UV AGRAVATED DISEASES PMLE SLE DLE SCLE Solar Urticaria
Xeroderma Pigmentosa
Chronic Actinic Dermatitis
Cockayne’s Syndrome, Blooms
PCT
Dermatomyositis
Pemphigus
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?
Dovonex
Vectical
Tazorac
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)
Litt’s 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 MD’s 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. Response to Sun Exposure
Fitzpatrick Skin Type
Fitzpatrick Skin Type
Response to Sun Exposure
Examples I
Always burns, never tans
Fair skin and freckles, blue eyed, Celts II
Always sunburns, tans minimally
Fair skin, blond hair, blue eyes, Scandinavian
III
Sometimes sunburns, tans moderately
Fair skin, brown hair, brown eyes, unexposed skin is white IV
Seldom sunburns, tans easily
Light brown skin, dark hair, brown eyes, unexposed skin is tan; Mediterranean, Hispanic V
Rarely sunburn, tans profusely
Brown skin; Darker Mediterranean, some Asians, Pacific Islander, Indian subcontinent VI
Never sunburns, deeply pigmented
African Americans

36. Fitzpatrick Skin Type I

37. Fitzpatrick Skin Type II

38. Fitzpatrick Skin Type III

39. Fitzpatrick Skin Type IV

40. Fitzpatrick Skin Type V & Type III

41. Fitzpatrick Skin Type VI

42. Initial NB UVB Dosing based on Fitzpatrick Skin Type
Tanning Response
Initial NB UVB Dose I
Always burns, never tans
100 mJ II
Usually burn, tans with difficulty
220 mJ
III
Sometimes mild burn, tan average
260 mJ IV
Rarely burns, tans with ease
330 mJ V
Very rarely burns, tans very easily
350 mJ VI
No burn, tans very easily
400 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
Interval Increase
Estimated Dose Goal
Maximum Dose
(not to exceed) I
15mJ
520 mJ
2000mJ II
25mJ
880 mJ
III
40mJ
1040 mJ
3000mJ IV
45mJ
1320 mJ V
60mJ
1400 mJ
5000mJ VI
65mJ
1600 mJ

45. Key Safety Points …….Burn Unit!!! Type of box: Remember units matter:
NB vs. BB
For clinics with multiple boxes
even if same light system
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 pt’s light box

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 
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/ cm2
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/cm2
Maximum dose is mJ /cm2
Missed Treatments of NBUVB for Vitiligo:
4-7 days 100% (same as last dose)
8-14 days decrease dose by 50%
15-21 days start over

57. Fig. 134.5 Narrowband phototherapy for vitiligo.
Before treatment
after 10 mos of NB UVB twice weekly
© 2003 Elsevier - Bolognia, Jorizzo and Rapini: Dermatology -

58. What’s 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, 10 -9th m), travelling through space at velocity, c (3x10 8th m/s), such that E=hc/lambda, where h= 6.63 X th J/s (Planck’s 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/cm2 )
Irradiance = Power delivered to a unit area (W/m2)