Dr. Elisabeth Richard discusses phototherapy in today’s practice, including usage trends, its continued role in the treatment of numerous skin diseases, and the importance of continuing to offer it to patients as a therapeutic option.
Elisabeth G. Richard, MD, Assistant Professor, Johns Hopkins Dermatology, Baltimore, Maryland
“Why do I like phototherapy? I did my residency at Johns Hopkins and had the opportunity to train under Warwick L. Morison, MD, one of the pioneers of phototherapy. I joined him in his private practice in 2009, where we had a practice focused on photomedicine, including phototherapy and photosensitive disorders,” said Elisabeth G. Richard, MD, who presented “Biologics are everywhere. Why Care About Phototherapy?” during the AtlanticDerm Conference in Baltimore, Maryland.
According to Dr. Richard, today she uses many approaches, including biologics (as monotherapy and in combination), as well as phototherapy, to treat patients with psoriasis, eczema, vitiligo, and a “laundry list” of other skin diseases that respond to light.
Phototherapy usage trends in the U.S. suggest dramatic declines in the 1990s, followed by more recent slight increases, she said.
“There was a study in the JAAD in 2002 which was an early look at trends in phototherapy … that predates the approvals of the initial biologics. [The authors] looked at data from 1993 to 1998 from the National Ambulatory Medical Care Survey, which unfortunately was only 589 records. They extrapolated that across 15 million office visits. It was pretty gloom-and-doom kind of data, showing a 90% decrease in phototherapy over those five years.”1
Explanations for the decline included poor compliance, poor reimbursement, fear of skin cancer, and the promise of newer therapies, said Dr. Richard.
“The question then was, is the sun starting to set on phototherapy?”
Maybe not. In 2018 there was study in the JAAD that looked at Medicare billing data from 2000 to 2015, a time period during which biologics were being approved. Etanercept (Enbrel, Amgen) was first approved in 2002 for psoriatic arthritis and in 2004 for psoriasis. Adalimumab (Humira, Abbvie) was approved in 2005 for psoriatic arthritis and in 2008 for psoriasis.
Researchers found that phototherapy services increased by 5% annually, said Dr. Richard.
“Of that, narrowband UVB was the greatest percentage of the volume, with 74% in 2015 and an overall 6% annual growth. Excimer laser grew to account for about 22% of that volume. Notably, Medicare covered the excimer laser starting in 2003. And psoralen plus ultraviolet A (PUVA) decreased by 9%.”2
Phototherapy Rules of Thumb
The most commonly used modality in phototherapy is narrowband UVB, said Dr. Richard.
“When I’m counseling patients I tell them a clearance course is typically about 25 to 30 treatments. We treat patients 2 or 3 times a week. I advise them that consistency key and they should really stick to their schedules. And if they’re itching, the itching tends to diminish around treatments 6 to 10. Patients appreciate this fact because it’s usually the itching and pruritis that’s driving them crazy.”
Typically, about 80% to 90% of her patients are about 80% to 90% better at the end of that initial clearance course, she said.
“After the clearance course, comes maintenance for most disorders. The majority of patients can maintain their improvement with once-a-week treatment using narrowband UVB for chronic disorders.”
As a general rule of thumb, if it’s an inflammatory disorder, light probably won’t hurt, said Dr. Richard.
These guidelines generally apply across all disease states, ranging from the big 3 in Dr. Richard’s practice—psoriasis, eczema, and vitiligo—to a whole host of other diagnoses, she said.
A Note About Vitiligo
Vitiligo is entering an exciting age with the approval of ruxolitinib 1.5% cream (Opzelura, Incyte) in July 2022, said Dr. Richard.
“There was an open-label study that looked at patients who had an initial 52 weeks of ruxolitinib cream alone and then started them on concomitant narrowband UVB. After at least 12 weeks of concomitant combination therapy, their facial vitiligo scores improved, and their total body vitiligo scores improved. Notably, of these patients that did this open-label prospective study, the majority had not really responded to the ruxolitinib cream alone, so that tells us that this is really great news for vitiligo patients.”3
The Phototherapy “Laundry List”
Pharmaceuticals are changing the landscape for some major diagnoses but there’s a whole host of diagnoses that Dr. Richard said she considers the “laundry list” that still very much utilizes and depends on phototherapy treatment.
“First and foremost, cutaneous T-cell lymphoma, mycosis fungoides, [and] lymphomatoid papulosis. Those are definitely at the top of the list to treat with phototherapy as a first-line treatment.”
Others on the list include lichen planus and other lichenoid processes (including lichenoid drug reactions), photosensitivity and polymorphic light eruption, checkpoint inhibitor dermatitis, pityriasis lichenoides chronica (PLC) and pityriasis lichenoides et varioliformis acuta (PLEVA), pityriasis rosea, granuloma annulare, graft-versus-host disease, and morphea and other scleroses skin disorders.
Biologic Prescribing Challenges
Not every psoriasis, eczema, or atopic dermatitis patient gets 100% response from biologics, said Dr. Richard.
“There’s what I call the therapeutically challenging patient—we’ve all had them. You’ve tried drug A, B, and C and are beating your head against the wall. You don’t have great control. Supplementing with topicals really isn’t cutting it. Everybody’s frustrated. If it’s an inflammatory process, that’s a great patient to think about adding phototherapy. It may be old school but it’s really a great adjunct for recalcitrant disease.”
Many patients are not medical or financial candidates for biologic or oral therapy, said Dr. Richard.
“Many patients prefer non-systemic options. It really is medically and financially responsible to review the option of phototherapy with each and every patient. Phototherapy should be presented to all patients, along with their systemic options.”
Then there’s the issue of what injectable and oral medications for these skin diseases cost the health care system, she said.
“We do have some data on what phototherapy costs. It’s from 2010. The annual cost of phototherapy in 2010 dollars for a treatment of let’s say psoriasis, would cost the system $2300 annually. If we adjust that for recent Medicare reimbursement changes, that goes up to about $3600. As reference, a course of methotrexate annually is about $1300.”
Comparatively, according to a 2018 article, adalimumab costs $51,000 annually, brodalumab $38,000, ixekizumab $65,000, secukinumab $57,000, and ustekinumab $57,000, said Dr. Richard.4
“There’s definitely a cost differential.”
Patient autonomy is important, she said.
“Patients have the right to make informed decisions about their health care. So, ask the patient what they want, give them their options and let them make an educated choice.”
“I’ll sum up by saying if you’re considering your therapeutic options, remember that phototherapy still works as monotherapy. It’s a great adjunct therapy. It has a great [safety and efficacy] profile. It’s very cost effective, has high patient satisfaction. … bring on your dermatoses and inflammatory processes, we still have the healing power of light and should not be afraid to use it.”
References:
- Housman TS, Rohrback JM, Fleischer AB Jr, Feldman SR. Phototherapy utilization for psoriasis is declining in the United States. J Am Acad Dermatol. 2002;46(4):557-559. doi:10.1067/mjd.2002.120451 Phototherapy utilization for psoriasis is declining in the United States – ScienceDirect]
- Tan SY, Buzney E, Mostaghimi A. Trends in phototherapy utilization among Medicare beneficiaries in the United States, 2000 to 2015. J Am Acad Dermatol. 2018;79(4):672-679. doi:10.1016/j.jaad.2018.03.018.
- Pandya AG, Harris JE, Lebwohl M, et al. Addition of Narrow-Band UVB Phototherapy to Ruxolitinib Cream in Patients With Vitiligo. J Invest Dermatol. 2022;142(12):3352-3355.e4. doi:10.1016/j.jid.2022.05.1093.
- Wu JJ, Feldman SR, Rastogi S, et al. Comparison of the cost-effectiveness of biologic drugs used for moderate-to-severe psoriasis treatment in the United States. J Dermatolog Treat. 2018;29(8):769-774. doi:10.1080/09546634.2018.1466022
Disclosure: Dr. Richard reports no conflicts of interest.