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Personalizing Home Phototherapy

An array of units of different sizes and designed for different purposes has been developed and allows for treatment of many different types of diseases (anatomic locations and distribution), ranging from full-body, to scalp, to hand and foot treatment (Table 2). Smaller, specialized units, such as handheld devices, allow for targeting of specific body areas and eliminate exposure of unaffected skin to ultraviolet light. The ability to perform such localized treatment may be more efficacious in treating certain diseases, particularly hand and foot diseases that require more intense regional treatment to penetrate the thick stratum corneum. For patients with more diffuse or total-body disease, the addition of reflecting side panels and wings increases the dispersion of ultraviolet rays, thus allowing a greater area to be well-treated in a uniform manner and in a lesser amount of time. Maximization of lamp output facilitates a shorter and more effective treatment session. A list of home phototherapy unit suppliers can be found on the National Psoriasis Foundation's website [40].

Practical use considerations

Prior to the initiation of a home phototherapy regimen, patients should undergo examination by their dermatologist to determine skin type and to establish diagnosis [46]. Additionally, a previous therapeutic response to outpatient phototherapy should be documented. The patient should be thoroughly educated as to practical use issues and goals of phototherapy as well as the anticipated response to and possible side-effects of treatment. The goal of therapy is to achieve clearing of psoriatic lesions within a period of several weeks without significant reddening/burning of the skin. The patient should be taught to differentiate between therapeutic response to treatment and adverse events, specifically reddening/burning versus painless pinkness of the skin. Additionally, patients should be educated as to proper and safe use of phototherapy equipment, including protection of eyes with UV goggles and covering of the genitals (for men) and nipples (for women). Patients should be informed of the importance of appropriate and consistent distancing from phototherapy equipment (1 foot is most desirable), which may be best achieved by using tape or other markings to indicate the desired distance. Finally, the importance of maintaining regular follow-up appointments, which are required to monitor response to phototherapy and to adjust dose appropriately, must be emphasized and understood by the patient.

Protocols for home phototherapy

A variety of protocols for home phototherapy have been developed and are tailored to fit different diseases, skin types, and minimal erythema dose (MED) [46]. A standard protocol for NB-UVB in the treatment of psoriasis consists of three sessions per week (treatment sessions every other day is most effective) for a duration of three months, with initial treatment time determined by skin type or MED and dose escalation depending on the patient's response to treatment and the physician/clinic preferences. For NB-UVB phototherapy, initial treatment time/dose may be based on the patient's skin type or MED. For MED-based NB-UVB regimens, 0.7 MED is the most frequently used initial dose, with recommended range of 0.5 - 1.0 MED [47, 48, 49, 50, 51, 52]. In terms of increase in treatment time, the magnitude of dose increase depends on the patient and the provider. There are a variety of strategies to increase treatment time: some increase the dose in increments of 10-20 percent with each treatment session; others use larger dose increments (15-20%) early in the course of treatment followed by smaller increments (10%) later on [44, 53]. Whereas MED-based therapy is thought to be safest, treatment time based on the patient's skin type is more convenient and as such is utilized by many practitioners [54]. For skin type-based regimens, the initial treatment time is based on the patient's Fitzpatrick Skin Type (Table 3 and Table 4) and subsequent increases in treatment time are based on skin type and response to the most recent treatment. If slight erythema or pinkness of the skin results from the most recent treatment, the patient should be instructed not to increase the treatment time. If reddening or sunburn occurs, patients should be instructed to stop treatment until reddening resolves and to resume treatment at one-half the previous exposure time. If no erythema or pinkness of the skin resulted from the most recent treatment, patients should be instructed to increase their treatment time based on skin type (Table 5). With body MED-based and skin type-based regiments, phototherapy sessions are continued until total remission is achieved or no further improvement can be attained [49].

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