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RESULTS

Evidence supporting their utilization

As a first step to delineating the efficacy of home delivery of UV as a treatment, we describe the evidence for the efficacy of ultraviolet phototherapy in general. In the subsequent section, we discuss the research supporting the effectiveness of home phototherapy in the treatment of photoresponsive dermatoses.

Broad-band (BB) UVB phototherapy

Phototherapy with UVB spectrum light (290-320 nm) has been used to treat psoriasis for at least the past seventy years [5]. Immunosuppressive effects of phototherapy are likely a major component behind its efficacy. The proposed mechanism of action involves induction of apoptosis in both T lymphocytes and keratinocytes, leading to decreased inflammation and epidermal hyperplasia [6]. Exposure to UVB, either as a sole intervention or in combination with emollients or tar preparation, is an effective therapy in the treatment of psoriasis. UVB is effective alone, as psoriatic lesions improve in response to treatment with erythemogenic doses of UVB without the concurrent use of topical agents [7]. Successful clearance of psoriasis using UVB, with or without petrolatum, typically occurs within 6 weeks of treatment [8, 9, 10, 11, 12]. Weekly regimens range from 3 to 5 exposures per week, with an average of 25 doses to achieve clearance (n=30). Prolonged remission can be maintained with UVB treatments once every 1 to 5 weeks [11].

Narrow-band (NB) UVB phototherapy

Narrow-band (NB) UVB phototherapy is emitted by Philips TL01 lamps and consists of a subset of the UVB spectrum, with a peak at 311 nm. The development of NB-UVB in the 1980s has resulted in the ability to select the wavelength at which optimal response is achieved while minimizing the erythemogenic response to non-therapeutic wavelengths. Parrish and Jaenicke (1981) conducted a study to determine the optimal ultraviolet spectrum for use in phototherapy for psoriasis and demonstrated that the peak action spectrum for clinical efficacy is between 308 and 312 nm [13]. These findings form the basis for selective UV phototherapy. Maximal erythemogenic response occurs around 297 nm, which is absent in the newer NB-UVB light emitting devices. NB-UVB has a significant therapeutic effect in the treatment of psoriasis, eczematous conditions, pruritus, cutaneous T-cell lymphoma, and vitiligo [14, 15, 16, 17].

Narrow-band UVB phototherapy has a more profound efficacy compared to conventional BB-UVB, achieving faster and more complete clinical response of psoriatic plaques [18]. Coven et al. (1997) assessed this efficacy by comparing NB-UVB to BB-UVB, both with and without tar, in the treatment of patients with moderate-to-severe psoriasis. Their results confirmed that NB-UVB is superior, with clinical resolution in 86 percent of sites treated with NB-UVB versus 73 percent treated with BB-UVB and histopathological resolution in 88 percent of sites treated with NB-UVB and 59 percent of sites treated with BB-UVB [19]. Additionally, clinical resolution occurred more rapidly using NB-UVB, generally within two to three weeks of treatment [19]. These results were reproduced by a subsequent study involving psoriasis patients undergoing split-body treatment consisting of three sessions per week for six weeks using NB-UVB and conventional BB-UVB. Results demonstrated clinical clearing in 81.8 percent of patients on the NB-UVB side and 9.1 percent of patients on the BB-UVB side (n=11) [20]. Histopathological examination revealed reversal of epidermal hyperplasia in 75 percent of patients on the NB-UVB side compared with none on the BB-UVB side [20].

Comparisons using the split-body approach have been made to assess the relative efficacy of trimethylpsoralen bath PUVA and NB-UVB in patients with chronic plaque psoriasis [21, 22]. The decrease in Psoriasis Area and Severity Index (PASI) score was greater on the NB-UVB side compared with topical PUVA, and this difference occurred earlier during the course of treatment on the NB-UVB treated side. Additionally, NB-UVB treatment was associated with fewer side effects and better tolerability. These results suggest that NB-UVB is more effective, efficient, and better tolerated compared to topical PUVA in the treatment of chronic plaque psoriasis psoriasis [22]. Comparisons of PUVA with oral psoralen versus NB-UVB phototherapy demonstrate that PUVA is more effective and efficient in clearing and maintaining remission in patients with chronic plaque psoriasis (n=93). Clearance was achieved in 84 percent of patients treated with PUVA, after an average of 17 treatments compared to NB-UVB treatment, which resulted in clearance for 65 percent of patients after an average of 28.5 sessions (n=93). Remission at six months was 68 percent in the PUVA group versus 35 percent in the NB-UVB group. However, the side effects associated with PUVA were greater, with 49 percent reporting erythema in the PUVA group compared to only 22 percent in patients undergoing NB-UVB [23]. It should also be noted that this study used twice-weekly dosing with NB-UVB versus the standard 3-5 times per week of UVB phototherapy. Because PUVA is also associated with potential systemic side effects (erythema, pruritus, nausea, ocular damage, and increased risk of skin cancer) as well as death from accidental overexposure, it is generally not recommended as an option for home phototherapy [24, 25, 26].

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