Phototherapy indications
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Phototherapy: Indications
Phototherapy uses UV radiation — with or without a photosensitizer — to treat a wide spectrum of skin disorders. The modalities include narrowband UVB (NB-UVB, 311–313 nm), broadband UVB (BB-UVB), PUVA (psoralen + UVA), UVA1 (340–400 nm), and 308-nm excimer laser.
Therapeutic Indications
1. Psoriasis
First-line indication for phototherapy. NB-UVB has replaced BB-UVB as the optimal UVB modality. PUVA (oral or bath) is highly effective, especially for recalcitrant disease. Monochromatic 308-nm excimer laser can target individual plaques. Palmoplantar pustulosis is also responsive.
- Dermatology 2-Volume Set 5e, block 3
2. Vitiligo
NB-UVB and PUVA are two of the leading treatments. NB-UVB is preferred over PUVA since it is easier and likely safer; ≥75% repigmentation achieved in 12.5–75%+ of patients. The 308-nm excimer laser is considered first-line for localized vitiligo. Response begins with perifollicular repigmentation; face, neck, and trunk respond better than extremities.
- Fitzpatrick's Dermatology, block 31
3. Atopic Dermatitis (AD)
NB-UVB, BB-UVB, UVA1, combined UVAB, and PUVA all have roles. UVA1 is particularly effective for severe acute exacerbations. UVA1 and NB-UVB show comparable efficacy. Mechanism involves reduction of epidermal Langerhans cells, eosinophil depletion, and T-lymphocyte apoptosis.
- Fitzpatrick's Dermatology, block 4
4. Mycosis Fungoides (Cutaneous T-Cell Lymphoma, stages IA/IB)
NB-UVB (broadband or narrowband), PUVA, and UVA1 are all used. NB-UVB is slightly inferior to PUVA in clearing MF but is preferred due to ease of use and safety. PUVA remains the mainstay for recalcitrant or thicker-plaque disease.
- Fitzpatrick's Dermatology, block 31; Dermatology 5e, block 3
5. Morphea (Localized Scleroderma)
UVA1 is the phototherapy of choice (followed by BB-UVA, then PUVA). NB-UVB is less effective due to shallower penetration. Treatment involves 30–36 sessions; ≥60% of patients show marked improvement or resolution. Mechanism includes upregulation of collagenase (MMPs) promoting collagen breakdown.
- Dermatology 5e, block 10
6. Lichen Planus (Generalized)
PUVA and NB-UVB are recognized treatments for generalized cutaneous lichen planus.
- Fitzpatrick's Dermatology, Table 199-1
7. Urticaria Pigmentosa (Mastocytosis)
PUVA and UVA1 have demonstrated benefit. UVA1 also reduces dermal mast cell numbers.
- Fitzpatrick's Dermatology, Table 199-1; Dermatology 5e, block 29
8. Cutaneous Graft-Versus-Host Disease (GVHD)
Both acute and chronic sclerodermoid GVHD respond to UVA1. Combination with low-dose systemic retinoids enhances response.
- Dermatology 5e, block 10 & 29
9. Pityriasis Lichenoides
PUVA and NB-UVB are used, though experience is limited to smaller case series.
- Fitzpatrick's Dermatology, Table 199-1
10. Lymphomatoid Papulosis
Phototherapy is used; evidence limited.
- Fitzpatrick's Dermatology, Table 199-1
11. Pityriasis Rubra Pilaris
PUVA is an option; evidence limited.
- Fitzpatrick's Dermatology, Table 199-1
12. Granuloma Annulare (Generalized)
PUVA is reported as effective.
- Fitzpatrick's Dermatology, Table 199-1
Prevention of Disease Symptoms (Hardening/Desensitization)
| Condition | Mechanism |
|---|---|
| Polymorphous light eruption (PLE) | Desensitization with low-dose UVB or PUVA in early spring |
| Solar urticaria | Tolerance induction |
| Chronic actinic dermatitis | Controlled UV exposure |
| Hydroa vacciniforme | Prophylactic low-dose phototherapy |
| Erythropoietic protoporphyria | Narrowband UVB for skin hardening |
- Fitzpatrick's Dermatology, Table 199-1
Neonatal Indication
Neonatal hyperbilirubinemia (jaundice): phototherapy is the primary treatment to reduce unconjugated bilirubin. Exchange transfusion is indicated if bilirubin rises despite intensive phototherapy or exceeds age-specific AAP thresholds.
- Tintinalli's Emergency Medicine; Rosen's Emergency Medicine
Contraindications (Summary from Dermatology 5e)
| Contraindication | Applies to |
|---|---|
| Genetic photosensitivity disorders (e.g., xeroderma pigmentosum) | UVB & PUVA (absolute) |
| Current skin cancer (SCC, melanoma) | UVB & PUVA (absolute) |
| Pregnancy / lactation | PUVA (absolute) |
| >150–200 cumulative PUVA treatments | PUVA (absolute) |
| Concurrent cyclosporine | UVB & PUVA |
| Photosensitive dermatoses | Both (adjust dose) |
| Skin phototype I | Both (adjust dose) |
| Phototoxic medications | Both (adjust dose) |
| Impaired liver function | PUVA |
| Cataracts | PUVA |
Modality-Indication Summary
| Modality | Primary Indications |
|---|---|
| NB-UVB (311 nm) | Psoriasis, vitiligo, AD, MF (early), PLE, lichen planus |
| PUVA | Psoriasis (recalcitrant), MF, vitiligo, palmoplantar disease, morphea, GVHD, lichen planus |
| UVA1 (340–400 nm) | Morphea/scleroderma, acute/sclerodermoid GVHD, AD (severe flares), mastocytosis |
| 308-nm excimer laser | Localized vitiligo (first-line), localized psoriasis plaques |
| BB-UVB | Largely replaced by NB-UVB; historically used for psoriasis |
Sources: Fitzpatrick's Dermatology (9780071837781); Dermatology 2-Volume Set 5e (9780702082252); Tintinalli's Emergency Medicine (9781260019933); Rosen's Emergency Medicine (9780323757898)
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