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Systematic Review of Phototherapy in Pruritic Disorders

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Systematic Review of Phototherapy in Pruritic Disorders Systematic Review of Phototherapy in Pruritic Disorders Soham Chaudhari, BA,* Argentina Leon, MD,** Ethan Levin, MD,** John Koo, MD*** *Medical Student, 4th year, Touro University Nevada – College of Osteopathic Medicine, Henderson, NV **Research Fellow, Department of Dermatology, University of California, San Francisco, CA ***Professor and Vice Chairman, Department of Dermatology; Director, Psoriasis Treatment Center, University of California, San Francisco, CA Abstract Phototherapy is a proven method for the management of many pruritic disorders, including atopic dermatitis (AD), prurigo nodularis (PN), and generalized pruritus (GP). Objective: This review aims to give an update on the use of phototherapy for managing pruritus in these disorders to establish it within the spectrum of possible therapeutic options. Methods: A thorough literature search of the PubMed database was conducted to identify studies that examined a variety of phototherapy methods in these disorders. Results: AD is best managed with narrow band (NB)-UVB. NB-UVB and broad band (BB)-UVB are also effective in decreasing pruritus in PN. BB-UVB is the preferred modality to decrease GP caused by uremic pruritus (UP). Conclusion: Phototherapy is a safe and beneficial option when other measures fail to control pruritus in these disorders. Introduction Methods Atopic Dermatitis Pruritus, or the sensation of itch, is the most For this systematic review, we concentrated on AD is a common, chronic inflammatory skin common symptom among dermatology patients.1 the therapeutic role of phototherapy for AD, disease characterized by intense pruritus leading Both cutaneous and systemic conditions may PN, LSC, and GP in adults. The computerized to secondary cutaneous findings. It is a genotypic present with pruritus as the primary symptom. bibliographic database PubMed was used to diathesis in which a heightened immune response is triggered once the skin is irritated Chronic pruritus is a major cause of distress conduct a search for English articles from by an environmental stimulus, subsequently to patients and has a significant impact on inception to August 2014. Research articles producing the sensation of itch. Genetically quality of life. All ages are affected by pruritus, of randomized controlled trials (RCT), predisposed individuals have an imbalance in the ranging from children to seniors, and it is the open prospective studies, pilot studies, and T-helper (Th) 2 versus Th1 immune responses. most common dermatologic complaint in the retrospective observations on NB-UVB, BB- 2,3 UVB, UVA, PUVA, and MEL were used. The AD develops secondary to this intensified latter group. For many sufferers of pruritus, following key words were used: phototherapy immune response once the patient continuously topical therapy is not adequate in controlling 6 pruritus, phototherapy eczema, phototherapy scratches. Hence, AD is colloquially known in their symptom. Therefore, providing additional atopic dermatitis, phototherapy prurigo dermatology as “the itch that rashes,” because therapeutic options becomes essential for the nodularis, phototherapy lichen simplex chronicus, the itch is the chief symptom and the foremost successful dermatologist. Phototherapy is a phototherapy neurodermatitis, and phototherapy indicator of treatment efficacy. safe and efficacious management modality that pruritic disorders. Based on the keywords chosen, decreases pruritus and can be used across age 1,194 articles were revealed. After screening title NB-UVB: 4 groups. and abstract, those studies in which phototherapy The reduction of pruritus in AD by NB-UVB Ultraviolet-based therapy (phototherapy and was not used as a treatment for the chosen disease radiation has been demonstrated in multiple photochemotherapy) can provide relief for processes were excluded. Reference lists in review studies (Table 1). A double-blind RCT was pruritic patients without many of the risks and articles were also searched. Abstracts-only and conducted by Reynolds et al. to compare the adverse effects of systemic medications. UVB duplicates were excluded. This left 105 articles efficacy of NB-UVB to BB-UVA and a placebo for the screening phase. These records were then 7 (290-320 nm) and UVA (320-400 nm) are of visible fluorescent light. The NB-UVB group assessed for eligibility, excluding children, hand implemented in UV-based therapy. Broadband experienced a 90% reduction in pruritus from eczema, nummular eczema, and other modes of UVB (BB-UVB) and broadband UVA (BB- baseline, compared to 63% reduction in the BB- treatment as primary analysis, thereby leaving 58 UVA group. When compared to placebo, there was UVA) use a light source covering their entire studies. Relevant data including study design, spectrum. Narrowband UVB (NB-UVB) uses a 38% greater reduction in pruritus for NB-UVB number of participants, duration of treatment, versus an 11% reduction for BB-UVA. Seventy- 311-313 nm, and UVA1 uses 340-400 nm with cumulative phototherapy dosing, adverse effects, one percent of patients had an improvement in a peak at 365 nm. UVA1 can be administered at and clinical outcome were retrieved from 2 their loss of sleep when on NB-UVB, as opposed high-dose (HD-UVA1) (130 J/cm ), medium- the articles and formulated into spreadsheet 2 to 53% on BB-UVA. NB-UVB also showed an dose (MD-UVA1) (50 J/cm ), and low-dose databases. Thus, the total number of trials included 2 improvement in disease activity in the three- (LD-UVA1) (20 J/cm ). Monochromatic excimer in the final analysis is 58. When specific pruritus month follow-up period. Although patients light (308 nm), or MEL, is a more targeted assessment scales were mentioned, we cited them in this study were allowed to use moderate-to- phototherapy device that delivers 308 nm UVB in the results. If no particular assessment scale potent topical steroids simultaneously, their use to a localized area and can expand treatment was used, extent of disease, sleep improvement, was quantified and included in the evaluation of options by sparing unaffected areas. This review and remission were evaluated. Because pruritus is treatment efficacy. This is in line with the real- the main symptom of these disorders, the above article focuses on the efficacy of these forms of world usage of phototherapy, as dermatologists phototherapy to treat non-psoriatic, chronic, criteria may be considered synonymous with the resolution of pruritus. rarely use phototherapy-only in practice. Other pruritic disorders triggered by an inflammatory studies that evaluated the use of NB-UVB support response including atopic dermatitis (AD), these positive results.8-11 In a nonrandomized, prurigo nodularis (PN), lichen simplex chronicus Results single-blind, half-side comparison study between (LSC), and generalized pruritus (GP). To our We separated our data based on our disease NB-UVB and the combination treatment of knowledge, this type of review has not been processes of interest, and further viewed each UVA and UVB (UVAB), NB-UVB significantly published before for phototherapy of pruritus. category of phototherapy based on current reduced pruritus (mean visual analogue scores widespread availability and use. 2.7 and 3.8; p=0.043).12 Legat et al. conducted Page 42 SYSTEMATIC REVIEW OF PHOTOTHERAPY IN PRURITIC DISORDERS Table 1: Phototherapy for treatment of pruritus in atopic dermatitis (AD) Study Type Participants (no.) Treatment Regimen Cumulative Dose (J/cm2 ) Concomitant TCS Pruritus Outcomes allowed NB-UVB RCT7 - NB-UVB: 22 2x/week (wk) for 24 - NB-UVB: 24.8 Yes NB-UVB > BB-UVA > placebo - BB-UVA: 19 weeks (wks) - BB UVA: 315 - Visible light - Placebo: 320 minutes (placebo): 19 RCT, open8 21 3x/wk for 12 wks NB-UVB: 35.05 Yes - 68% reduction in AD severity scores - 88% reduction in TCS use RCS9 37 2x/wk NB-UVB: 21.9 Yes 81% improved RCS10 40 3x/wk NB-UVB: 16.371 Yes 80% improved RCT, BCS12 10 3x/wk for 6 wks - NB-UVB: NR Yes NB-UVB > UVAB - UVAB: NR RCT, BCS13 9 3x/wk for 8 wks - NB-UVB: 26.7 No NB-UVB = MD-UVA1 - MD-UVA1: 1000 RCT, BCS14 13 3x/wk for 8 wks - NB-UVB: 10.5 In follow-up NB-UVB = MD-UVA1 - MD-UVA1: 930.6 period RCT, CoS15 47 3x/wk for 6 wks - NB-UVB: 23.4 No NB-UVB = MD-UVA1 - MD-UVA1: 880 RCT11 5 5x/wk for 3 wks NB-UVB: 9.2 No 100% patients improved BB-UVB RCT, BCS16 17 3x/wk for 8 wks - BB-UVB: NR Yes BB-UVB > placebo - Daylight tubes (placebo): NA CS17 1* 2x/wk for 3 months - BB-UVB: NR No BB-UVB > NB-UVB - NB-UVB: NR RCT19 - BB-UVB: 52 5x/wk - BB-UVB: 2.70 No UVAB > BB-UVB - UVAB: 54 - UVAB: 1.77 (UVB), 104 (5) RCT20 89 UVAB > BB-UVB RCT21 - BB-UVB: 33 5x/wk - BB-UVB: 2.3 Yes UVAB > BB-UVB - UVAB: 23 - UVAB: 1.4 (UVB) 160 (5) PUVA RCT, BCS23 - Whole-body PUVA - PUVA: 3x/wk - PUVA: 13 No PUVA > BB-UVB & placebo vs. control: 5 - BB-UVB: 5x/wk - No treatment: NR - PUVA vs. no - BB-UVB: NR treatment: 5 - PUVA vs. BB- UVB: 5 RCT24 113 PUVA: 3x/wk for 8 wks PUVA: 115.3 80% decrease in severity RCT, BCS27 12 PUVA: 3x/wk for 6 wks - NB-UVB: 14 No PUVA = NB-UVB - Bath PUVA: 48.3 CoS2 40 - MOP+UVA: 3x/wk for - PUVA: 48.1 No PUVA > MD-UVA1 5 wks - MD-UVA1: 1138.8 - MD-UVA1: 5x/wk for 3 wks UVA1 RCT, BCS29 - UVA + UVAB: 28 - UVA + UVAB: 5x/wk - UVA (361) + UVAB: Yes - UVA = UVAB - BB-UVB + UVAB: for 3 wks 0.466 (UVB), 109 (5) - UVAB > BB-UVB 20 - BB-UVB + UVAB: 3x/ - BB-UVB (0.282) + UVAB: wk for 8 wks 0.558 (UVB) 130(5) RCT30 - HD-UVA1: 15 Daily for 15 total - HD-UVA1: 1950 No HD-UVA1 > UVAB - UVAB: 10 exposures - UVAB: NR RCT31 - HD-UVA1: 20 Daily for 10 total - HD-UVA1: 1300 No HD-UVA1 > fluocortolone
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