Narrow-band ultraviolet B home phototherapy was found to be an effective form of maintenance therapy for photoresponsive diseases.

AUTHORS: Haykal KA, DesGroseilliers JP.
Division of Dermatology, University of Ottawa, Canada. khayk097@uottawa.ca

BACKGROUND: Phototherapy is an effective treatment for several photoresponsive diseases. Many patients are unable to attend hospital-based treatment and prefer home phototherapy.

OBJECTIVES: The purpose of this study is to survey patients who were prescribed home phototherapy to determine the viability of narrow-band ultraviolet B home units in the continuous or maintenance treatment of photoresponsive diseases.

METHODS: A patient questionnaire was prepared focusing on different areas of interest: the reason for choosing home therapy, appropriate teaching, previous medical treatment, present exposure therapy, improvement of the condition, side effects, regular dermatologic follow-ups, and the effectiveness of this approach. Twenty-seven patients who attended the photodermatology clinics at the Sisters of Charity of Ottawa Health Service at the Elisabeth Bruyère Health Centre in Ottawa and the Ottawa Hospital Civic Campus were contacted, and they completed a questionnaire by telephone or electronic mail.

RESULTS: Twenty-five patients completed the questionnaire. One refused to participate, and one was out of the country. The main reasons for choosing home phototherapy were time (40%), travel expenses (25%), difficulty with work schedule (17%), and recommendation by a physician (6%). Other reasons included loss of earnings, personal stress, knowledge that the disease recurs when phototherapy is discontinued, moving from the city, personal stress, and the convenience of being at home. Regarding the effectiveness of the home phototherapy, 24 patients (96%) viewed the home unit approach to be effective. All patients agreed that they would continue the treatment; they would repeat it, and they would recommend it. Few patients reported side effects, such as erythema (36%), blisters (1%), pruritus (8%), and dryness (1%). Fourteen patients (56%) reported not experiencing any side effects.

CONCLUSION: Narrow-band ultraviolet B home phototherapy was found to be an effective form of maintenance therapy for photoresponsive diseases. It is safe and presents few side effects when patients receive appropriate guidelines, teaching, and follow-ups.

PMID: 17234107 [PubMed - indexed for MEDLINE]
Article Source http://www.ncbi.nlm.nih.gov/pubmed/17234107
2006 Sep-Oct;10(5):234-40

The spectrum of light is broken up into several pieces such as UV (ultraviolet), IR (infrared) and of course visible light. UV and IR are not visible to the naked eye but each affects our skin and in the case of IR can be felt as heat on the human skin. UV light is not seen or felt but it can have profound and lasting effects on the skin in beneficial and sometimes harmful ways.

Image from http://www.homephototherapy.com/nbc-narrowband.htm

Looking at the image above, one should notice that

1) The red line is our skin’s sensitivity to UV light
2) The blue line is what we call UVB Broad Band
3) The green line is UVB Narrow Band

The entire article can be seen by <Clicking Here>

This report examines the dosimetry of ultraviolet (UV) radiation applied to dermatological treatments, and considers the definition of the radiation quantities and their measurement. Guidelines are offered for preferred measurement techniques and standard methods of dosimetry. The recommendations have been graded according to the American Joint Committee on Cancer classification of strength of recommendation and quality of evidence.

The article discusses options and ideas for treatement. I have listed links at the bootom of this posting to other ideas to help with treatment guidlines.

Recommendations and guidelines

1. Whole-body treatments should be given in ventilated cabins surrounding the patient with radiation sources wherever possible, and it is recommended that obsolete apparatus be replaced. (American Joint Committee on Cancer classification: BIII)
2. Phototherapy clinics should use a UV radiometer to measure irradiances from all UV treatment equipment. The meter should have minimal response outside the UV band and be chosen for dynamic range, linearity and angular sensitivity. (BIII)
3. The meter should be calibrated annually for each type of UV source in use, identifying the method, its traceability to known national standards and the waveband over which irradiance is measured. Irradiance over the full UV band of 250–400 nm should also be measured, in addition to any other band width, to facilitate intercomparisons. (BIII)
4. Built-in UV dosimeters in cabins should agree closely with directly measured irradiance values. Where agreement is outside reasonable tolerance (± 10%), the built-in meter may need adjusting. The supplier or the person responsible for the equipment should be consulted for advice. (BIII) The webmaster has an opinion on the use of dosimetry in home systems <Click Here>
5. Electrical equipment should be tested for compliance with electrical safety standards, and staff should be trained to operate the equipment correctly. Annual checks are acceptable, and written records should be kept. (BIII)
6. Regular consistency checks of all UV irradiation apparatus should be performed, by checking for failed lamps and measuring UV irradiance in a standard reference location to identify any changes. Failed lamps should be replaced promptly, and consistency verified at least monthly. (BIII)
7. Skin irradiances should be measured regularly by the Direct or Indirect Methods, and used to calculate exposure times and to check built-in meters. Measurement every 25–50 h of usage is acceptable, but after installing new lamps, which degrade more quickly when new, re-measure after 10–15 h. (BIII)
8. Patient doses should be prescribed in J cm)2 (or derived units), and cumulative doses calculated and recorded at the end of treatment courses, to quantify lifetime exposure to therapeutic UV. (BII-i)
9. MED ⁄ MPD techniques should be described fully, including the site(s) of test(s), the criteria used to assess erythema, the methodology of masking and exposing test sites, including any devices used for this, and the sequence of doses used (or the ratio between adjacent exposures). (BII-iii)
10. The recommendations in this report should be subject to routine audit, as part of the clinic’s audit programme, to verify that objectives are being met, and to optimize clinical outcomes.

Useful Links and Articles

• This article in Full <CLICK HERE>
• UVB Narrow Band: A Practcal Approach <CLICK HERE>
• Initiating Narrow-band UVB for the treatment of Psoriasis <CLICK HERE>

Here’s a brochure from Philips that I’m sure you’ll find interesting: <CLICK HERE>

A fluorescent lamp or fluorescent tube is a gas-discharge lamp that uses electricity to excite mercury vapor. The excited mercury atoms produce short-wave ultraviolet light that then causes a phosphor to fluoresce, producing visible light. Wikipedia does a much better job of describing fluorescent lights than I ever could. <<Click Here >>

Philips is the sole maker of UVB Narrow Band lamps at this time. Philips lamps with a “/01″ phosphor are the ones you’ll find in the UVB Narrow Band products we sell <<Click Here>>

UVB Narrowband Spectrum

In the graphic to the above, you’ll see two graphs, one depicting the UVB Broadband spectrum and the other is the UVB Narrowband spectrum which is a very narrow group of wavelengths centered around 311 nm, sometimes UVB NB or Narrow Band is called UVB311.

UVB NB or UVB Narrow Band has replaced PUVA and UVB Broadband in the majority of phototherapy applications today.

We (AMJO CORP) have never run into this before.

There are four HCPCS Codes that we typically file under, these are E0691, E0692, E0693 and E0694, all essentially defining the same equipment in different size ranges.

It seems insane to me that they do not cover all four codes. All the other insurance companies do, some have different allowable amounts for each class but to my knowledge, Humana is the only one that differentiates between the codes.

Medicare does cover E0694 for Psoriasis but not for other diseases.

Read Humana’s Policy (Click Here) (See Page 7 and

Once again we are befuddled by an insurance company!

Although not tested yet, Humana’s policy does read “To qualify for home services, members must be confined to the home, or the condition is such that leaving the home for required services would require considerable effort, impose significant hardship, or expose the patient to undesirable risk.” This sentence may cause claims to be denied also.

Basically, If I had an option I would not choose Humana as an insurance company if I were expecting to benefit from insurance coverage for Ultraviolet UVB Narrow Band) Therapy.

Handisol II UVB Narrow Band Panel

We are introducing a new UVB Narrow Band panel suitable for the treatment of Psoriasis, Vitiligo, Eczema and a host of other skin challenges and diseases. Weighing in at sixteen pounds, this new panel is light, portable and will travel very well.

This new product will use the newest of the UVB Narrowband Lamps released by Philips, the world leader in UVB Lamps for phototherapy. The new PL-L-36W/01/4P lamp allows the construction of a highly energy efficient light weight phototherapy system. We are truly thankful to the folks at Philips for creating this new lamp. This lamp style (PL36) has been around for a while and the visible light (non UV) form of this bulb has been used for many years in products to treat Seasonal Affective Disorder. You can see many of these products at Amjo’s www.sadlight.com and www.lightenupshop.com websites. These remarkable lamps generate twice the power of the TL20W/01 lamps used in our two foot tall (nominal) systems.

Handisol II

The new Handisol II UVB NB panel  weighs in under 20 lbs. We fully expect that this unit will be one of our largest revenue producers in 2011.

You will need to contact Chris Cane (That’s me) to learn more. This Handisol II is priced agressively. Give me a call 513-942-2770. We will be adding this to our www.HomePhotoTherapy.com website in the very near future.

Effective home phototherapy treatment of psoriasis, vitiligo, and other skin diseases. Handisol II lets you treat the most difficult areas quickly and effectively.

• Exclusive Controlled Prescription Timer^® assures control of your treatment regimen
• High output for quick, effective treatment
• Large window and reflective backing behind lamps provides coverage area of over 2 square feet
• Key lock to prevent unauthorized use
• Slim, lightweight, and portable makes storage and setup easy
• Clear acrylic shield for easy cleaning and optimum light energy
• Shipped fully assembled, ready for immediate use.

I decided to do some web surfing and have learned that she might be on the right track.

Elsewhere in this blog at http://www.uvbnarrowband.com/index.php/2010/01/uva1-phototherapy-is-it-effective I did write about UVA-1 and its apparent success with Granuloma Annulare.

First a little reading about the disease.

A little reading from several sites provided this information.
For some images of the disease; See http://tinyurl.com/granuloma-annulare

Overview

Granuloma annulare is a long-term (chronic) skin disease consisting of a rash with reddish bumps arranged in a circle or ring.

Causes
Granuloma annulare most often affects children and young adults. It is slightly more common in girls. The condition is usually seen in otherwise healthy people. Occasionally, it may be associated with diabetes or thyroid disease. Its cause is unknown.

Symptoms
Granuloma annulare usually causes no other symptoms, but the rash may be slightly itchy. Patients usually notice a ring of small, firm bumps (papules) over the backs of the forearms, hands, or feet. Occasionally, multiple rings may be found. Rarely, granuloma annulare may appear as a firm nodule under the skin of the arms or legs.

Treatment
I did find an article at http://tinyurl.com/4phduov discussing the use of UVB Narrow Band with Granuloma Annulare and this study concluded that:

• Mayo Clinic: http://www.mayoclinic.com/health/granuloma-annulare/DS00793
• Medline: http://www.nlm.nih.gov/medlineplus/ency/article/000833.htm
• WebMD: http://www.webmd.com/skin-problems-and-treatments/granuloma-annulare
• Google Health: https://health.google.com/health/ref/Granuloma+annulare

LAS VEGAS – Improved understanding of itching and best practices in management of the condition may lead to U.S. medical centers specializing in treating pruritus.

A recent gathering of experts convened by the National Institutes of Health (NIH) may be the first step in this direction, Dr. Timothy G. Berger said at a dermatology seminar sponsored by Skin Disease Education Foundation.

Dr. Timothy G. Berger

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) pulled together 50 physicians on Oct. 29, 2010, to discuss the topic of pruritus. One of a series of roundtable discussions held by NIAMS, this was the first to focus on itching. A summary of the meeting and a list of attendees will be posted on the NIAMS website by the end of 2010, NIAMS media liaison Trish Reynolds said in an interview.

“These things are usually followed by calls for proposals,” said Dr. Berger of the University of California, San Francisco (UCSF), who did not attend the roundtable discussion. “The NIH is moving to a model of having major itch referral centers at several sites.”

Patients with itch would be referred to a center where their tissue samples and data could be stored and analyzed while they get expert treatment. “There will be direct translational benefits” from this approach, he predicted.

These centers would be patterned after two models – referral centers for pain, and European itch centers. The U.S. itch centers might first appear at UCSF; Washington University, St. Louis; and Harvard University, Boston, he said.

“In Europe, every patient with itch goes to a medical center for itch, is seen in a standard way, and has a defined database established about that patient. They now have tens of thousands of itch patients of various types logged into this database,” and data it provides are helping to build greater understanding of the problem of itching, Dr. Berger said.

One of the key insights into itching in recent years has been the understanding that chronic itch is like chronic pain. Chronic itch is thought to begin peripherally but then trigger anatomic changes in the CNS that make treatment much more difficult. “This suggests that we will have agents that will act both peripherally and centrally” to ease itching, he said. “We’re now at the verge of being able to do something about itching.”

Chronic itching should be treated aggressively because once central sensitization occurs, it is very, very hard to manage, he advised. Chronic itching has a huge impact on quality of life, earning the same scores by patients as the reduced quality of life reported by patients with chronic renal failure on dialysis.

Once itch is chronic, the threshold for sensation of itch is reduced. “Even if you make their rash better, they still itch,” he said. Itch intensity increases with chronicity, producing more itch from the same rash. Even when the skin is clear, patients may have short bursts of spontaneous itch. In atopic dermatitis and perhaps some other forms of itchy lesions, patients may scratch themselves raw because inflammatory mediators of pain are perceived as itch.

“This whole system is miswired” in chronic itch, Dr. Berger said.

Perceived itch is a delicate interaction between the skin, nerves, and immune system, and treatments may target or more of these pathways. The most common medication for chronic itch is second-generation antihistamines, in higher doses than used for the approved indication of allergic rhinitis. “These substances also block other inflammatory mediators that may be important for itch, so they may have benefit beyond what we know,” Dr. Berger said.

Neuroleptic medications for itch include amitriptyline or other tricyclic antidepressants, gabapentin, pregabalin, duloxetine, or thalidomide for prurigo nodularis. “These act primarily on the neural axis,” he said.

Central-acting agents include paroxetine, amitriptyline, doxepin, or mirtazapine. In a large European cohort, 6-9 months of treatment with paroxetine reduced chronic itch by 75% in 70% of patients. “It’s now become one of our drugs to treat itch, and is the treatment of choice for itch in polycythemia vera,” he said.

Research has shown that patients with liver disease can develop itch caused by abnormalities in opiate metabolism, leading some clinicians to treat chronic itch with naltrexone, butorphanol or other agents that act on the opiate pathway.

Phototherapy also has been used to treat chronic itch, including narrow-band UVB, psoralen plus UVA, or broadband UVB for itch associated with renal disease. “Phototherapy probably has an immunomodulatory effect that can benefit itch,” Dr. Berger said.

Several European itch centers incorporate a biopsychosocial approach to managing itch. As with chronic pain, focusing on the itch through education and support from nurses helps reduce the itch and decrease feelings of helplessness or inability to cope. Patients miss less work and report more low-itch days and improved quality of life. “So, there’s a biopsychosocial aspect that probably will need to be addressed,” he said. Some U.S. centers have employed this approach in managing atopic dermatitis.

Dr. Berger has been a consultant for Prescription Solutions and received research funding from GlaxoSmithKline, Clinsys Clinical Research, Merz Pharmaceuticals, and Pharmanet, none of which is relevant to this topic, he said. All the medications for itching that he discussed are used off-label. SDEF and this news organization are owned by Elsevier.

The article and citations can be found in its entirety at Skin and Allergy News – Click Here

Typical UVB Narrowband Cabinet

We’ve seen a few reports out of New Zealand with respect to the use of ultraviolet light. Here’s one I added to our blog in July: < click here > 

Recently (12 October) another article was posted about the use of UVB and kids. The study involed  116 children. Here’s the essence of the article.

Background:  Phototherapy is effective for many dermatoses in adults, but there is a paucity of data for its use in children. 

Objectives:  To review the efficacy and tolerability of narrowband UVB phototherapy in children at a tertiary centre in New Zealand, and determine if there were any factors that differentiated responders from non-responders. 

Methods:  A prospective analysis of children (<16 years old) who had undergone phototherapy over a 15-year period. 

Results:  116 children received phototherapy with a total of 144 courses. Mean age was 11.0 years with the majority being European and having skin phototype II. Atopic dermatitis was the most common indication for treatment followed by psoriasis, pityriasis lichenoides, nodular prurigo, morphea, vitiligo, urticaria pigmentosa and erythropoietic porphyria. Treatment was effective in the majority of children (72%). Most received only one course. For responders, the mean number of treatments was 32.4. The mean dose per treatment to achieve clearance was 886 mJ/cm2 and the mean maximum treatment dose per treatment was 1328 mJ/cm2. All children tolerated treatment well with 36% developing brief, minimally symptomatic, erythema. Only two children experienced exacerbations of their underlying dermatoses. 

Conclusions:  This study shows that phototherapy is an effective and well-tolerated treatment modality in children. 

UVB Narrowband products for home and clicical use can be found at www.homephototherapy.com

The part of the sun’s spectrum that we concern ourselves with is the Ultraviolet portion which is by definition 200 nM to 400 nM (nM is nano meter or a billionth of a meter). The UV Spectrum is broken up (by definition) into three bands, UVA, UVB and UVC. Science has arbitrarily defined these as

• UVA – Long Wavelength             320 to 400 nm
• UVB – Medium Wavelength       290 to 320 nm
• UVC – Short Wavelength            200 to 290 nm (Sometimes called ‘Germicidal Light’)

UVB Narrow Band is a small slice of the UVB Spectrum at 311 nM and is identified as that part of the UV Spectrum that seems to provide the optimal therapeutic effect with the lowest risks including lower risk of cancer, lower risk of sunburn and very low risk of contributing to premature skin aging.

OK I’m rambling a bit. People ask, how does UVB NB equate to sunlight? This is an impossible question to answer.

This question is impossible to answer as the sun’s measurable output varies depending on:

• Our Latitude.
• The time of day.
• The season.
• The time of year.
• Cloud cover.
• Relative humidity.
• One’s elevation.

Suffice it to say, one of the advantages of UV Phototherapy is the constancy that one can achieve in one’s treatment from day to day.

Sunlight presents a ‘full spectrum’ of UV light whose energy level arriving on the surface of our planet is dependent on all of the above factors and perhaps others.

Hope this helps?

Do you have any suggestions?