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Advantages of home phototherapy

The advantages of home phototherapy to both doctor and patient are numerous and include convenience, lower cost, better adherence to treatment, and improved quality of life [55]. In terms of treatment effectiveness, adherence is one of the most important factors in determining clinical outcomes. Patients' adherence to home phototherapy regimens is high and may be even better than to oral psoriasis treatment [32]. Furthermore, improved quality of life, which is attributable to a certain form of treatment, is likely to foster better adherence to that treatment.

Convenience

Repeated journeys to the hospital or outpatient offices for phototherapy pose an obvious inconvenience and expense. Geographic, work, and economic constraints compound the difficulty for patients to maintain an adequate treatment schedule. Treatment plans which are too complicated, costly, or time-consuming may increase the burden of chronic disease. Convenience factors played a major role in patients' decisions regarding mode of treatment and adherence to treatment. In a survey of patients undergoing home phototherapy, forty percent of users identified ��time�� as their reason for selecting home phototherapy and an additional seventeen percent chose it due to ��difficulty with work schedule�� [4]. Other reasons relating to convenience included ��convenience of being at home�� and ��moving from the city�� [4]. In another survey, 42 percent of patients undergoing outpatient phototherapy described this method as ��inconvenient�� and 75 percent indicated that home phototherapy would be helpful [31]. The importance of convenience factors and the relationship between convenience and adherence has been emphasized in the dermatology literature [56]. Additionally, technological advances in equipment design have made home phototherapy units more convenient. Home phototherapy units now operate on standard house electrical current. Many have convenience features, such as casters, which allow for easy moving; adjustable wheels that ease movement on any type of floor surface; and wings or doors, which can be closed or folded away for easy storage (Table 2).

Cost

The cost of long-term management of severe psoriasis has risen dramatically with the recent development of injectable immunomudulators. There is significant variability in cost and efficacy of different treatment options and patients may respond better to some treatments than others [55]. Cost, both direct and indirect (loss of work and from social and family activities), is an important consideration in optimizing treatment outcomes. In a payer-perspective cost model that compared the direct expenditures associated with the long-term management of psoriasis using various treatments, home UVB phototherapy was less costly than any other treatment for severe psoriasis (including methotrexate, PUVA, acitretin, and biologic agents) [55]. Additionally, a survey of patients using home phototherapy demonstrated that 25 percent of patients chose home phototherapy due to travel expenses associated with outpatient phototherapy [4]. Loss of earnings associated with missing time from work to attend outpatient phototherapy sessions was another factor contributing to patients' preference for home phototherapy [4]. These findings, in conjunction with the efficacy and safety profile of home UVB phototherapy, render it a cost-effective choice for long-term management of photoresponsive dermatoses [55].

Adherence

Poor adherence to treatment is ubiquitous in dermatology. With regards to home phototherapy, concerns arise about the possibility of over use, under use, and inappropriate use [39]. Proper patient education and the presence of newer safety features installed in home phototherapy units help ensure appropriate use of home units [3]. Few studies have addressed the issue of adherence to home phototherapy. One recent study of patients with moderate-to-severe psoriasis assessed adherence to oral acitretin and home UVB phototherapy. Patients were instructed to use home phototherapy three times per week, along with daily oral acitretin, for twelve weeks. Adherence to the home phototherapy regimen was good throughout the study, with patients using phototherapy between two and three times per week [57]. Adherence to the oral acitretin, however, decreased over the 12 week trial period. Side effects of the treatment did not appear to impact adherence [57]. Adherence to home ultraviolet phototherapy was better than oral acitretin. Selection of patients interested in participating in a home phototherapy trial could have contributed to this difference, however. Patients' perception of the effectiveness of a treatment can also influence adherence. Perception of the effectiveness of home phototherapy is very good, with 96 percent of patients reporting positive results [4]. Additionally, treatment satisfaction is greater with home phototherapy, as 43 percent of these patients reporting ��excellent�� treatment, compared with 23 percent of patients undergoing standard outpatient phototherapy [33].

Quality of life

Many patients with chronic dermatologic disease report decreased quality of life and adverse characteristics of treatment as major factors contributing to the impact of psoriasis. Home phototherapy and standard outpatient phototherapy are associated with significant and similar increases in quality of life. However, home phototherapy is associated with a significantly lower burden of treatment [33]. A greater sense of control, self-confidence, and well-being may be achieved with home phototherapy [58]. Home phototherapy, which eliminates the burden of travel, time lost from work, and interference with other family and social activities, is more convenient, less stressful, and poses fewer impediments to normal life [4]. Stress is thought to be a factor in psoriasis exacerbations. Thus, home phototherapy, which reduces patient stress levels in response to outpatient visits, may prove to have a beneficial effect in reducing the number and frequency of exacerbations in psoriasis patients.

Medico-legal issues and monitoring

As with any form of prescribed treatment, there are certain medico-legal issues that must be considered. Medico-legal issues are not a major obstacle in the use of home phototherapy regimens for a variety of reasons. These include: proper patient selection (limiting its use to patients with prior demonstrated therapeutic response to phototherapy and who can be relied on to maintain regular follow up), built-in control devices (such as the prescription controlled timers which limit number of sessions between office visits), and the history and documented record of the safety of home phototherapy compared to other alternatives (such as methotrexate, which has systemic toxicities). Adequate monitoring with close clinical follow up ensures that treatment is safe and effective. This also allows for the regimen to be adjusted in the event of suboptimal response to treatment or reported adverse events.

CONCLUSION

Home phototherapy is an effective means of treating chronic photoresponsive dermatoses. Efficacy, lower cost, convenience of use, and better quality of life all contribute to patient preference and better adherence. The development of narrow-band UVB and safety features for the various home units have helped to make this form of therapy more appropriate and less hazardous. The variety of sizes and options offered by the newer home phototherapy units allows better treatment of different areas and distributions of disease. Cost has become an even more important consideration in evaluating medical treatment options and home phototherapy is less costly than many alternatives. Home phototherapy has broadened therapeutic options, improved the quality of life for many patients, and should be considered as a primary treatment option for psoriasis treatment.

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