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Functional impairment of epidermal Langerhans cells and dermal dendritic cells and reduced
expression of ICAM-1 and other adhesion molecules, resulting in a reduced capacity of antigen
presentation to effector T cells [13].
Topical dithranol, vitamin D derivatives, and retinoids in conjunction with narrowband UVB
phototherapy have been reported as beneficial in a few small uncontrolled studies [25-29].
Systemic retinoids such as acitretin increase the efficacy of phototherapy, particularly in patients with
chronic plaque psoriasis [30]. Retinoids hasten and enhance the response to phototherapy and reduce
treatment frequency, duration, and cumulative UVB doses [19,31]. However, despite its many
advantages, retinoid-UVB therapy is infrequently used. (See "Treatment of psoriasis", section on
'Retinoids'.)
Methotrexate may have a synergistic effect with UVB therapy for the treatment of psoriasis. In a small
randomized trial, patients treated with methotrexate and narrowband UVB achieved a >90 percent
reduction of the baseline psoriasis area and severity index (PASI) more rapidly than patients treated
with placebo plus narrowband UVB (median time 4 weeks versus >24 weeks) [32]. However, further
studies are needed to confirm the efficacy of this combination therapy and evaluate potential short- and
long-term adverse effects.
Several reports suggest that narrowband UVB phototherapy may enhance the therapeutic response to
biologics [33-37]. However, long-term safety data on these combinations are not available and there is
concern that concurrent treatment with anti-TNF agents and narrowband phototherapy may increase
the risk of photocarcinogenesis [35,38-40].
SAFETY MEASURES Safety measures for patients undergoing UVB phototherapy include:
SHORT- AND LONG-TERM ADVERSE EFFECTS Short-term adverse effects of UVB phototherapy
include erythema, skin dryness, pruritus, blistering, and increased frequency of recurrent herpes simplex
(table 5).
Long-term adverse effects include photoaging and the possibility of photocarcinogenesis. The carcinogenic
potential of narrowband phototherapy has not been determined. A systematic review of the carcinogenic risk
associated with PUVA and narrowband UVB therapy for psoriasis suggests that narrowband UVB therapy
does not increase the risk of skin cancer [45]. However, there is a need for larger studies with longer follow-
up time to assess the risk of skin cancer among patients treated with narrowband UVB phototherapy.
CONTRAINDICATIONS Absolute contraindications for UVB phototherapy are:
Relative contraindications to UVB therapy include:
SUMMARY AND RECOMMENDATIONS
Wearing UV-blocking goggles to protect the eyes and prevent conjunctivitis and photokeratitis
Protecting the face (if not involved in the disease process) either by using a sunscreen with an SPF of
50+ or a cloth barrier
Protecting the genitalia (if not involved in the disease process) by wearing underwear
Avoiding concurrent natural sun exposure
Xeroderma pigmentosum
Lupus erythematosus
History of photosensitivity diseases (eg, chronic actinic dermatitis, solar urticaria)
History of melanoma
History of nonmelanoma skin cancer
History of treatment with arsenic or ionizing radiation because of the increased risk for skin cancer
Immunosuppression for organ transplant patients
Narrowband UVB (311 to 313 nm) is the type of phototherapy most frequently used for the treatment of
moderate to severe psoriasis and a wide range of skin diseases, including atopic dermatitis, vitiligo,
early stages of mycosis fungoides, and pruritic disorders (table 1). (See 'Introduction' above.)
The main cytochemical target of UVB is nuclear DNA. The UVB-induced DNA damage stimulates
signal transduction pathways leading to the activation of transcription factors, cytokine secretion,
immunosuppression, and a variety of cellular responses, including cell cycle arrest and apoptosis. (See
'Principles and mechanisms' above.)
Devices for broadband UVB therapy utilize fluorescent lamps emitting a wide range of wavelengths,
mostly in the UVB range (280 to 320 nm) and, in part, in the UVA range (figure 1). Devices for
narrowband UVB therapy use the TL-01 fluorescent lamps that emit UVB in the range of 311 to 313
nm. (See 'Devices for broadband and narrowband UVB' above.)
Treatment is generally started with an initial dose of UVB equal to 50 to 70 percent of the minimal
erythema dose (MED) or at a dose determined by the patients phototype (table 4). It is important to
document the type of lamp used for MED determination, since values obtained with broadband or
narrowband sources are markedly different (table 3). (See 'Dosimetry and treatment protocols' above.)
The radiation dose is then gradually increased by 10 to 40 percent of the previous dose. The goal of
dose increment is to achieve a minimally perceptible erythema, which is the clinical indicator of optimal
dosimetry. Treatment is continued until complete remission is achieved or no further improvement can
be obtained with continued phototherapy. The role for maintenance therapy is uncertain. (See
'Treatment initiation, frequency, and dose increments' above.)
The most common indications for UVB therapy, in particular for narrowband UVB, include moderate to
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19. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and
psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and
severe psoriasis that is unresponsive to topical therapy, severe atopic dermatitis, and vitiligo. (See
'Clinical indications for UVB therapy' above.)
During UVB phototherapy, the eyes must be protected with UV-blocking goggles. The face, genital
area, and skin that is not involved must be protected with an SPF 50+ sunscreen or a cloth barrier.
(See 'Safety measures' above.)
Short-term adverse effects of UVB phototherapy include erythema, skin dryness, pruritus, blistering,
and increased frequency of recurrent herpes simplex (table 5). Long-term adverse effects include
photoaging and photocarcinogenesis, although the carcinogenic potential of narrow band UVB is less
established. (See 'Short- and long-term adverse effects' above.)