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FROM THE ACADEMY

Guidelines of care for the management of psoriasisand psoriatic arthritis

Section 5. Guidelines of care for the treatment of psoriasis withphototherapy and photochemotherapy

Alan Menter, MD,a Neil J. Korman, MD, PhD,b Craig A. Elmets, MD,c Steven R. Feldman, MD, PhD,d

Joel M. Gelfand, MD, MSCE,e Kenneth B. Gordon, MD,fAlice Gottlieb, MD, PhD,g John Y. M. Koo, MD,h

Mark Lebwohl, MD,i Henry W. Lim, MD,j Abby S. Van Voorhees, MD,k Karl R. Beutner, MD, PhD,l,m

and Reva Bhushan, PhDn

Dallas, Texas; Cleveland, Ohio; Birmingham, Alabama; Winston-Salem, North Carolina; Philadelphia,

Pennsylvania; Chicago, Illinois; Boston, Massachusetts; San Francisco and Palo Alto, California;

New York, New York; Detroit, Michigan; and Schaumburg, Illinois

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and jointmanifestations affecting approximately 2% of the population. In this fifth of 6 sections of theguidelines of carefor psoriasis, we discuss the use of ultraviolet (UV) light therapy for the treatment of patients with psoriasis.Treatment should be tailored to meet individual patientsneeds. We will discuss in detailthe efficacy and safetyas well as offer recommendations for the use of phototherapy, including narrowband and broadband UVBand photochemotherapy usingpsoralen plusUVA, alone and in combinationwith topical and systemic agents.

We will also discuss the available data for the use of the excimer laser in the targeted treatment of psoriasis.Finally, where available, we will summarize the available data that compare the safety and efficacy of thedifferent forms of UV light therapy. ( J Am Acad Dermatol 2010;62:114-35.)

DISCLAIMERAdherence to these guidelines will not ensure

successful treatment in every situation. Furthermore,these guidelines should not be deemed inclusive of

all proper methods of care nor exclusive of othermethods of care reasonably directed to obtaining thesame results. The ultimate judgment regarding thepropriety of any specific therapy must be made by

the physician and the patient in light of all thecircumstances presented by the individual patient.

SCOPEThis fifth section will cover the management and

treatment of psoriasis with phototherapy.

METHODA work group of recognized psoriasis experts was

convened to determine the audience and scope ofthe guideline, and identify clinical questions tostructure the primary issues in diagnosis and man-

agement discussed in American Academy of

From the Psoriasis Research Center, Baylor University Medical Center,

Dallasa; M urdough Family Center for Psoriasis, Department of

Dermatology, University Hospitals Case Medical Center, Cleve-

landb; Department of Dermatology, University of Alabama at

Birminghamc; Department of Dermatology,Wake ForestUniversity

School of Medicine, Winston-Salemd; Department of Dermatology

and Center for Clinical Epidemiologyand Biostatistics,Universityof

Pennsylvaniae; Division of Dermatology, Evanston Northwestern

Healthcare and Department of Dermatology, Northwestern Uni-

versity, Fienberg School of Medicine, Chicagof; Tufts Medical

Center, Tufts University School of Medicine, Bostong; Department

of Dermatology, University of CaliforniaeSan Francisco;h Depart-

ment of Dermatology, Mount Sinai School of Medicine, NewYorki;Department of Dermatology, Henry Ford Hospital, Detroit;j De-

partment of Dermatology, University of Pennsylvania, Philadel-

phia;k Anacor Pharmaceuticals, Inc, Palo Alto;l Department of

Dermatology, University of California San Francisco;m and the

American Academy of Dermatology, Schaumburg.n

Funding sources: None.

The authors conflict of interest/disclosure statements appear at

the end of the article.

Reprint requests: Reva Bhushan, PhD, 930 E Woodfield Rd,

Schaumburg, IL 60173. E-mail: rbhushan@aad.org.

Available online October 8, 2009.

0190-9622/$36.00

2009 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2009.08.026

Abbreviations used:

AAD: American Academy of Dermatology

BB: broadbandFDA: Food and Drug AdministrationMED: minimal erythema doseNB: narrowbandPUVA: psoralen plus ultraviolet ASCC: squamous cell carcinomaUV: ultraviolet

114

mailto:rbhushan@aad.orgmailto:rbhushan@aad.org

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Dermatology (AAD) psoriasis guidelines sections1 and 2.1,2 Work group members completed adisclosure of commercial support.

An evidence-based model was used and evidencewas obtained using a search of the MEDLINE data-base spanning the years 1960 through 2009. OnlyEnglish-language publications were reviewed.

The available evidence was evaluated using aunified systemcalledthe Strength of RecommendationTaxonomy developed by editors of the US familymedicine and primary care journals (ie, AmericanFamily Physician, Family Medicine, Journal of Family Practice, and BMJ USA). This strategy wassupported by a decision of the Clinical GuidelinesTask Force in 2005 with some minor modificationsfor a consistent approach to rating the strength of theevidence of scientific studies.3 Evidence was gradedusing a 3-point scale based on the quality of meth-

odology as follows:I. Good-quality patient-oriented evidence.II. Limited-quality patient-oriented evidence.III. Other evidence including consensus guidelines,

opinion, or case studies.

Clinical recommendations were developed on thebest available evidence tabled in the guideline.These are ranked as follows:A. Recommendation based on consistent and good-

quality patient-oriented evidence.B. Recommendation based on inconsistent or lim-

ited-quality patient-oriented evidence.C. Recommendation based on consensus, opinion,or case studies.

In those situations where documented evi-dence-based data are not available, we have usedexpert opinion to generate our clinical recommen-dations. Prior guidelines on psoriasis were alsoevaluated. This guideline has been developed inaccordance with the AAD AdministrativeRegulations for Evidence-based Clinical PracticeGuidelines, which include the opportunity forreview and comment by the entire AAD member-

ship and final review and approval by the AADBoard of Directors.

GENERAL PRINCIPLESIn the past, conventional psoriasis therapiese

phototherapy, photochemotherapy, methotrexate,cyclosporine, and acitretinewere used when psori-asis was too extensive for topical therapy. Although aminimum body surface area (eg, 10%) has beentraditionally used as a prerequisite to starting ultra-violet (UV) light or systemic therapy for psoriasis, a

subset of patients with limited disease have

debilitating symptoms. For example, whereas severepsoriasis of the palms and soles or severe scalppsoriasis affects less than 5% of the body surfacearea, the significant negative effect on the quality oflife of the patient makes treatment with systemictherapies an appropriate approach to the manage-ment. Although treatment options for psoriasis haveexpanded in recent years, UV light therapy remainsan essential therapeutic option for patients withpsoriasis. Phototherapy is efficacious, is cost-effec-tive, and generally lacks the systemic immunosup-pressive properties of both traditional and biologicsystemic therapies.

Various spectra of UVB and UVA wavelengthshave been used to treat psoriasis. Although it hasbeen known for many centuries that some skindiseases improve with sun exposure, scientific in-vestigation of phototherapeutic modalities did not

begin until the late 19th century with the work ofNiels Ryberg Finsen who received the Nobel Prize in1903 for his work developing phototherapy for thetreatment of cutaneous tuberculosis. Goeckerman4

first described the use of broadband (BB)-UVB incombination with day and night applications ofcrude coal tar for the successful treatment of psori-asis. This therapy was carried out while patients wereadmitted to the hospital for several weeks. Duringthe years after the development of the Goeckerman4

regimen, several modifications and simplificationswere made. In the 1950s, the Ingram5 regimen was

developed, which replaced crude coal tar withanthralin. Subsequent studies have demonstratedthat a lubricating base may be used instead of crudecoal tar. However, a 1983 study demonstrated thatsuberythemogenic doses of UVB and coal tar weremore efficacious than UVB and a lubricating base.6,7

Clear emollients such as mineral oil also enhance theefficacy of UVB by improving the optical propertiesof the skin; their use facilitated the shift of UVB as anoutpatient, rather than an inpatient or day hospital,treatment modality.8-10 In the 1980s, a new type ofUVB bulb with a narrow emission between 311 and

313 nm was developed and found to have superiorefficacy to BB-UVB light11; this new UVB treatmentis now commonly referred to as narrowband(NB)-UVB therapy.

Because keratinocyte hyperproliferation is a hall-mark feature of psoriasis, it was originally believedthat the mechanism of action of UV light treatment inpsoriasis was through a direct effect of UV light onDNA by inhibition of cellular turnover. Withnewer evidence firmly demonstrating that psoriasisis an immunologic disease, the rol