Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Hospital supervised home narrowband ultraviolet B phototherapy
- Heather Cameron, Robert Dawe (18 May 2009)
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Home Phototherapy
- Jeremy Luke (20 May 2009)
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Re: Hospital supervised home narrowband ultraviolet B phototherapy
- Mayke BG Koek, Erik Buskens, Carla AFM Bruijnzeel-Koomen, Vigfús Sigurdsson (22 May 2009)
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Hazards of UVL
- Charles P Dupont, Dublin 4, Ireland (23 May 2009)
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Heather Cameron, Associate Specialist in Dermatology Ninewells Hospital, Dundee, Scotland, DD1 9SY, Robert Dawe
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We hope that the study by Koek and colleagues[1] will encourage others to implement supervised home ultraviolet B (UVB) phototherapy to treat people with psoriasis and other appropriate conditions. The first published report on home phototherapy using narrowband UVB (more effective for psoriasis than broadband UVB[2]) was our report of pilot studies of this approach.[3] We now have over 10 years experience of home phototherapy, with 16 home phototherapy units (Waldmann UV 100 [Waldmann, Villingen- Schwenningen, Germany] devices, as used by Koek et al.), which we lend out to patients, in almost constant use. We already have the sort of ‘hub and spoke’ model for provision of phototherapy, as well as other dermatology outpatient services, suggested by Professor Anstey in his editorial.[4] Despite our service including 3 separate peripheral hospital phototherapy units, as well as our central unit in Dundee, home phototherapy still has a place. In 2008, 25 of 818 (3%) of whole-body narrowband UVB courses administered by our service were home phototherapy courses. Most home phototherapy courses in our area are for psoriasis (155 [72%] of the last 216 courses were for psoriasis). However, with appropriate supervision, home narrowband UVB phototherapy is also useful for people with atopic eczema, for ‘desensitisation’ treatment of photodermatoses (including erythropoietic protoporphyria) and for a variety of other conditions. Our experience is that appropriate selection of patients is essential. This is in keeping with Koek and colleagues’ finding that only 196 patients attending 14 hospital units over 3 years met their study eligibility criteria. Also, to ensure that the treatment is as effective and safe as is hospital phototherapy, supervision and training of patients, as well as testing of devices and dosimetry measurements, must be supervised by the hospital-based phototherapy units. Our home phototherapy service is run within Photonet, the National Managed Clinical Network for phototherapy (established since 2002), so treatment is given to agreed protocols and all data is gathered centrally for long term analysis. This will also allow appropriate recall of patients for skin cancer monitoring if this becomes appropriate. We agree with Professor Anstey that extending phototherapy services for all, including providing supervised home phototherapy, is preferable to the widespread use of systemic therapies, including the ‘biological’ therapies for psoriasis which are not only costly but for which long term safety data is lacking. References: 1 Koek MB, Buskens E, van Weelden H et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009; 338: b1542. 2 Dawe RS. A quantitative review of studies comparing the efficacy of narrow-band and broad-band ultraviolet B for psoriasis. Br J Dermatol 2003; 149: 669-72. 3 Cameron H, Yule S, Moseley H et al. Taking treatment to the patient: development of a home TL-01 ultraviolet B phototherapy service. Br J Dermatol 2002; 147: 957-65. 4 Anstey A. Home UVB phototherapy for psoriasis. BMJ 2009; 338: b607. Competing interests: None declared |
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Jeremy Luke, GP Coachmans medical practice. Crawley West Sussex RH11 0JH
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Thank you for this excellent article. The pragmatic approach to research fits well with general practice. This type of research is the sort that inspires us to look for change. I will ask our local dermatologists about this option for treatment as it may well be one worth commissioning. Competing interests: None declared |
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Mayke BG Koek, research fellow dermatology University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands, Erik Buskens, Carla AFM Bruijnzeel-Koomen, Vigfús Sigurdsson
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We thank Cameron for the encouraging response[1] to our paper[2]. We suspect the illustrative approach described will facilitate implementation of home UVB phototherapy in the UK. In their response, however, they suggest that a careful selection of patients is essential to maintain and safeguard efficacy and safety. Moreover, they apparently assume that patients in our trial were also specifically selected[1]. The latter is not the case. We would like to stress that the patients enrolled in our study were a representative sample of patients considered clinically eligible[2,3]. Although, from 14 hospitals only 196 patients participated in our study, the type of selection Cameron is aiming at was not part of our eligibility criteria[2,3]. It should be noted that only 252 patients were referred to us for participation in the trial. It was unfeasible to keep a record of all reasons for non-referral, but from the few dermatologists who did keep a record we know that many patients were simply not willing to participate in the study. Also we are aware of the fact that it was often simply forgotten to ask a patient to participate. We noted that participants in our trial were people from all walks of life. Although we do not rule out that minimal selection has occurred, we are convinced that on average our participants adequately represent patients with psoriasis who receive (outpatient) UVB treatment outside the trial. As such, we disagree with Cameron, because from our trial and from our experience[4] we believe that there is little reason to select patients based on their presumed higher intelligence, competence, responsibility, reliability, or compliance[2]. References: (1) Cameron H, Dawe RS. Hospital supervised home narrowband ultraviolet B phototherapy. http://www.bmj.com/cgi/eletters/338/may07_2/b1542#213869 [2009] (2) Koek MBG, Buskens E, van Weelden H, Steegmans PH, Bruijnzeel- Koomen CAFM, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009; 338:b1542. (3) Koek MBG, Buskens E, Steegmans PHA, van Weelden H, Bruijnzeel- Koomen CAFM, Sigurdsson V. UVB phototherapy in an outpatient setting or at home: a pragmatic randomised single-blind trial designed to settle the discussion. The PLUTO study. BMC Med Res Methodol 2006; 6:39. (4) van Vloten WA. [Home treatment of psoriasis using ultraviolet-B irradiation]. Ned Tijdschr Geneeskd 1993; 137(49):2525-2526. Competing interests: None declared |
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Charles P Dupont, consultant dermatologist Baggott St Hospital, Dublin 4, Ireland
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Converting patients to physiotherapists overnight seems a bit optimistic. Were there no complications from the regime what about long term carcinogenesis? Is complete clearance of psoriasis necessary ? Is UVB addiction possible as well authenticated for sunbeds. a cost benefit analysis should be done and comparison with for example the short contact dithranol regime. Competing interests: None declared |
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