Efficacy of Acitretin and Commercial Tanning Bed Therapy for Psoriasis

STUDY Efficacy of Acitretin and Commercial Tanning Bed Therapy for Psoriasis

Christopher S. Carlin, MD; Kristina P. Callis, MD; Gerald G. Krueger, MD

Objective: To assess the efficacy of acitretin and com- had moderate improvement, and 2 (9%) of 23 had no mercial tanning bed therapy for the treatment of mod- improvement. Patients reported a high degree of satis- erate to severe chronic plaque-type psoriasis. faction with the treatment. In the prospective trial, the Psoriasis Area and Severity Index (PASI) and National Design: Retrospective medical record review and tele- Psoriasis Foundation scores decreased an average of phone survey of subjects and prospective open-label trial. 78.6% and 79.0% from baseline, respectively. A reduction from baseline in the PASI score of 50% and 75% Setting: University dermatology clinic. (PASI 50 and PASI 75) was achieved by 13 (76%) and 10 (59%) patients, respectively. Adverse events were Patients: The study population comprised 26 subjects generally mild to moderate. in the retrospective study and 17 subjects in the prospective study, all with moderate to severe plaque-type Conclusions: Acitretin use in combination with com- psoriasis. mercial tanning bed therapy appears to be effective and useful for psoriasis in areas without access to physician- Intervention: Twelve weeks of daily oral acitretin (25 directed phototherapy. The variability of tanning salon mg) therapy and commercial tanning bed UV exposure light and quality mandates caution when using this (mean UV-B output of 4.7%) for 4 to 5 days per week. therapy.

Results: In the retrospective review, 19 (83%) of 23 subjects had clearance or near clearance, 2 (9%) of 23 Arch Dermatol. 2003;139:436-442

HE COMBINATION of photo- ment of their psoriasis.8,9 A US survey of 113 therapy with retinoids has psoriasis patients who had used commer- been shown to be advanta- cial tanning bed light reported that 68% be- geous over either therapy lieved it to be an effective treatment mo- alone in the treatment of dality.10 A prospective study involving 20 moderateT to severe psoriasis. The combi- patients with moderate to severe psoriasis nation of UV-B with acitretin therapy (re– treated with commercial tanning beds for UV-B)1 and the combination of psoralen 6 weeks showed that 80% of patients had with UV-A (PUVA) with acitretin or etreti- a clinical improvement in the Psoriasis Area nate therapy (re-PUVA)2-4 have resulted in and Severity Index (PASI) score.11 A re- marked improvement in psoriasis with cent placebo-controlled study that ana- clearance rates of up to 100%. These regi- lyzed 38 patients who used UV-A tanning mens have been shown to work more rap- beds showed a small but statistically sig- idly than retinoids or phototherapy alone. nificant difference in reduction of PASI Since lower daily doses of retinoids are scores in 4 weeks.12 generally sufficient in combination treatment, tolerability is improved.5 Further- See also pages more, the number and duration of UV 443 and 520 treatments can be significantly reduced, potentially mitigating the long-term haz- Because other treatment modalities of From the Department of 6 Dermatology, University of ards of UV exposure. UV light have been shown to act synergis- Utah Health Sciences Center, Although physicians do not fre- tically with retinoids, it is important to as- Salt Lake City. The authors quently advocate commercial tanning bed certain whether commercial tanning bed have no relevant financial use,7 patients with psoriasis are known to light would also augment the therapeutic re- interest in this article. use commercial tanning bed light for treat- sponse to retinoids. To our knowledge, at

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Manufacturer- Measured UV-B Output, % Measured UV-A + UV-B Output, mW/cm2 Salon Lamp Type Reported UV-B No. of Site (Manufacturer) Output, % Patients Initiation 6 wk 12 wk 18 wk Mean ± SEM Initiation 6 wk 12 wk 18 wk Mean ± SEM 1 X5000 (Interlectric 5.0 4 4.9 4.6 4.6 4.8 12.0 14.9 13.6 13.2 Corporation, Warren, Pa) 2 Midday Sun 5.0 (Light 5.0 6 4.8 4.8 4.7 4.8 17.5 17.2 17.2 17.8 Sources, Inc, Orange, Conn) 4.7 ± 0.001 15.0 ± 1.36 3 Midday Sun 5.0 (Light 5.0 3 4.7 4.7 4.7 4.2 16.7 17.3 17.2 17.9 Sources, Inc) 4 Genesis 105 (Sun Industries, 4.6 3 4.6 4.3 4.6 4.8 14.7 11.9 10.9 10.6 Inc, Jonesboro, Ark)

*Does not include data from patient who used home unit.

present no studies exist that detail the efficacy of the com- with clinical assessment. The protocol was approved by the Uni- bination of retinoid and commercial tanning bed therapy. versity of Utah institutional review board, and all patients signed Because the University of Utah, Salt Lake City, serves a large the approved consent form. population of rural patients from the surrounding area and Patients were prescribed acitretin, 25 mg/d, and 5 to 7 tan- neighboring states, PUVA and UV-B phototherapy often ning sessions per week for a maximum of 12 weeks. Patients were advised to begin tanning bed exposure at 2 to 3 minutes per ses- are not reasonable options. From 1997 to 2000, the com- sion and to increase exposure by 1 minute per session until clear- bination of retinoid and commercial tanning therapy (re- ing or until a maximum exposure time (30 minutes) was reached. TBUV) was used in 26 patients with plaque-type psoria- Eye and genital protection was to be worn at all times within the sis. Based on the encouraging results, a prospective study tanning bed. Induction of slight erythema per light treatment was was then performed on 17 patients to further validate the the goal. If moderate erythema was present, the previous expo- combination treatment. In the present study, we summa- sure dose was maintained until regression of erythema oc- rize our experience with acitretin use in combination with curred. Other than 2 patients who used a concomitant cortico- commercial TBUV therapy. steroid or calcipotriene on their scalp, no other topical agent besides a moisturizer was used on the skin by any patient. Ac- METHODS itretin use was discontinued and tanning bed visits were reduced in patients who cleared before 12 weeks. RETROSPECTIVE STUDY Nineteen Wolff tanning beds (Wolff System Technology Corporation, Marietta, Ga) containing lamps that had a manu- A total of 26 patients attending the Dermatology Clinics at the facturer reported UV-B output close to 5% were evaluated. One University of Utah Health Sciences Center received retinoids (25 tanning bed at 4 different salons in the north, south, east, and received acitretin and 1 received isotretinoin) in combination with west of the Salt Lake Valley were selected for use based on com- commercial tanning bed therapy from 1997 to 1999. A retro- parable percent UV-B output. Output of UV light of the se- spective medical record review was performed on all 26 pa- lected tanning beds was measured every 6 weeks for the dura- tients to document severity of psoriasis, duration of psoriasis, tion of the study using a portable UV meter (IL-1350; past systemic and light therapies, dosage of acitretin, type of tan- International Light, Newburyport, Mass) with separate probes ning bed used, and duration of the combination treatment. to measure UV-A and UV-B output (Table 1). After lamps were Patients were retrospectively surveyed regarding compli- allowed to warm up for 20 minutes, output measurements for ance and satisfaction on a scale of 0% to 100%, with 100% being each bed was averaged from 6 readings from the center and 10 the best. Patients provided a global assessment of improvement inches from each end of the top and bottom bed halves. One of their psoriasis at the end of therapy compared with baseline patient used a Wolff bed at home that emitted similar light read- on a scale of –100% (most worsened) to 0 (no change) to 100% ings (UV-B=4.1%) as the other beds. (most improved). Patients also provided a global assessment of Each patient was evaluated at initiation and every 2 weeks their psoriasis on a scale of 1 to 10 by answering the following for 12 weeks using the PASI score13 and the National Psoriasis question: “If ‘1’ is equivalent to having no psoriasis and ‘10’ is Foundation (NPF) psoriasis score.14 The NPF score (Table 2) equivalent to their psoriasis being the worst ever, what was it at is totaled by adding the individual scores of 5 different com- the end of therapy?” An adverse event profile was generated from ponents: (1) induration of 2 target lesions, (2) body surface area the medical record review, laboratory tests, and patient survey. (BSA), (3) physician global assessment, (4) patient global assessment, and (5) patient assessment of itching. The NPF pso- PROSPECTIVE STUDY riasis score reference card was used to assess induration. The physician global assessment component is static and deter- A total of 17 patients were enrolled in the prospective trial. Pa- mined by averaging induration, erythema, and scale of all pso- tients selected for inclusion were at least 18 years old with stable riatic lesions. Similar to the PASI score, an NPF score of 0 sig- or worsening moderate to severe plaque-type psoriasis. Pa- nifies clearance. The maximum NPF score is 30. tients excluded from the study included women of childbear- Appropriate laboratory tests (fasting serum cholesterol, tri- ing potential (unless surgically sterile), men who would not glyceride, complete blood count, basic metabolic panel, and he- consent to practice birth control during the study, patients with patic function tests) were performed on weeks 0, 4, 8, and 12. a known sensitivity to light or retinoids, patients requiring pro- Adverse events were assessed at each visit. longed exposure to non–study-related UV light, patients with Efficacy data were analyzed on an intent-to-treat basis. moderate to severe liver or kidney disease, and patients When a mean was calculated for the group, the results were with skin disorders in the treatment area that would interfere expressed as the mean±SEM. Otherwise, all results were ex-

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Primary End Points Maximum Score Base of Assessment Assessment of induration† 5 (Plaque A) 0 = No elevation above surrounding normal skin; 1 = 0.25 mm (minimal); 2 = 0.50 mm (mild); 3 = 0.75 5 (Plaque B) mm (moderate); 4 = 1.0 mm (marked); 5 = 1.25 mm or greater (severe) Body surface area‡ 5 0 = 0%; 1 = 1%-20%; 2 = 21%-40%; 3 = 41%-60%; 4 = 61%-80%; 5 = 81%-100% Physician static global 5 Induration is scored as in Krueger.14 Erythema:0=noerythema except for residual hyperpigmentation; response§ 1 = faint; 2 = light red; 3 = moderate red; 4 = bright red; 5 = dusky to deep red. Scaling: 0 = none, 1 = minimal (occasional fine scale over Ͻ5% of lesion); 2 = mild (fine scale predominates); 3 = moderate (coarse scale predominates); 4 = marked (thick, nontenacious scale predominates); 5 = severe (very thick, tenacious scale predominates) Patient global assessment࿣ 5 0 = No psoriasis; 1 = 20% as bad as ever; 2 = 40% as bad as ever; 3 = 60% as bad as ever;4=80% as bad as ever; 5 = the worst that their psoriasis has ever been Patient assessment of itch 5 0 = No itch; 1 = mild (only aware of itching as times, only present when relaxing, not present when focused on other activities); 2 = intermediate between 1 and 3; 3 = moderate (often aware of itching, annoying, sometimes disturbs sleep and daytime activities); 4 = intermediate between 3 and 5; 5 = severe (constant itching, distressing, frequent sleep disturbance, interferes with activities) Additive Score of Primary 30 End Points

*Details of the NPF score have been published by Krueger14 and are available from the National Psoriasis Foundation, 6600 SW 92nd Ave, Suite 300, Portland, OR 97223-7195. †Performed using the NPF reference card for induration measurement. ‡Body surface area defined as 1% = palm to first interphalangeal joint, and is expressed as a ratio of body surface area relative to baseline. §Score is the global assessment of erythema, induration, and scaling averaged over all lesions. ࿣Assessment by patient of severity relative to worst psoriasis has ever been.

Table 3. Retrospective Study and Prospective Trial Patient Demographics and Treatment Data*

Medical Record Review Prospective Trial Demographic (n = 26) (n = 17) Age (range), y 43 ± 13.8 (19-72) 45.4 ± 11.9 (25-67) Sex, F/M 8/18 4/13 Duration of psoriasis, y 17.3 ± 10.6 18.6 ± 12.2 Past systemic/UV therapy PUVA (46.2%), methotrexate (46.2), retinoids (15%), PUVA (53%), methotrexate (41%), retinoids (12%), cyclosporine (12%), hydroxyurea (12%), UV-A (12%), cyclosporine (12%), hydroxyurea (12%), UV-B (4%), thioguanine (4%), sulfasalazine (4%), others interleukin 8 (12%), efalizumab (6%), others Psoriasis severity at initiation† Moderate (65%), severe (35%) Moderate (76%), severe (24%) Acitretin + UV treatment 19.4 ± 11.3 9.5 ± 3.3 duration, wk Acitretin dosage, mg/d 24.2 ± 10.0 25 ± 0.0 No. of UV treatments/wk 4.7 ± 1.5 4.1 ± 1.1 Total UV exposure per person, min Not available 715.5 ± 381.8 Total UV-A dosage per Not available 622.6 ± 245.5 person, J/cm2 Total UV-B dosage per Not available 29.9 ± 11.7 person, J/cm2 Type of tanning bed used Wolff‡ (58%), RUVA (12%), unknown (31%) Wolff‡ (100%)

Abbreviations: PUVA, psoralen with UV-A; RUVA, reflector UV-A. *Data are mean ± SD unless otherwise specified. † Arbitrarily defined by body surface area (Ն15% = severe, Ͻ15% = moderate). †Wolff System Technology Corporation, Marietta, Ga.

pressed as mean±SD. The Prophet 5.0 statistics program by BBN tients had moderate to severe plaque-type psoriasis for Systems and Technology, Cambridge, Mass, was used for sta- an average duration of 17.3 years. Most patients had used tistical analysis of the data. The primary outcome measure was at least 1 systemic agent in the past. The average dosage the PASI score. Body surface area and the NPF score were sec- of acitretin was 24.3 mg/d, and the average number of ondary outcome measures. The PASI and NPF scores at each light treatments per week was 4.7. Therapy outcome was visit were compared with baseline using the Kruskal-Wallis test with a significance level of 5%. grouped into 5 categories of global improvement compared with baseline: clearance (Ն90% improvement), near Ն Ͻ RESULTS clearance ( 75% to 90% improvement), moderate improvement (Ն50% to Ͻ75% improvement), mild im- Ͻ RETROSPECTIVE STUDY provement (25% to 50%) improvement, and no change (0% to Ͻ25% improvement). No patient experienced A total of 8 women and 18 men aged 19 to 72 years were worsening of psoriasis. A follow-up physical examina- enrolled in the retrospective study (Table 3). All pa- tion was available in 23 patients. Nineteen (83%) of 23

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15 P = .04 40 12 30% 30 P = .002 Score 9 P = .002 P = .002 Patients, % P > .99 20 6 P = .002 P = .66 9% 9% 10 3 P = .03 P = .002 P = .004 0% P = .002 0 0 No Change or Mild Moderate Near Clearance Baseline 2 4 6 8 10 12 Worse Improvement Improvement Clearance Weeks

Figure 1. Response to treatment per medical record review (n=23). Patients Figure 2. Prospective trial (n=17) mean response to combination of retinoid were grouped into categories depending on the percentage of reduction of and commercial tanning bed therapy of National Psoriasis Foundation (NPF) psoriasis: no change (0%-Ͻ25%), mild improvement (25%-Ͻ50%), moderate score, percentage body surface area (BSA), and Psoriasis Area and Severity improvement (50%-Ͻ75%), near clearance (75%-Ͻ90%), and clearance Index (PASI) score at baseline and every 2 weeks until study termination at (90%-100%). week 12. P values above each NPF value and below each PASI value reflect that value compared with the NPF and PASI baseline values, respectively. Error bars reflect the SD at that particular point. patients experienced clearance or near clearance of their psoriasis (Figure 1). The results of the patient survey, completed by 24 of the 26 patients, are given in the tabu- 100 lation below. 90 88 Survey Question Scale Mean±SD Value 80 76 Rank psoriasis at end of treatment (1-10) 2.5±1.7 70 59 Patient report of improvement (0%-100%) 73.5%±29.9% 60 Patient satisfaction (0%-100%) 71.7%±29.5% 50 47 Compliance (0%-100%) 76.9%±18.4%

Patients, % 40 PROSPECTIVE STUDY 30 20 12 A total of 4 women and 13 men aged 25 to 67 years were 10 enrolled (Table 3). All patients had moderate to severe 0 PASI <25 PASI 25 PASI 50 PASI 75 PASI 90 plaque-type psoriasis for an average duration of 18.6 years. Percentage of Reduction of PASI Score Because the first 2 to 3 minutes of UV-B exposure was approximately 20% lower than the maximum output, the Figure 3. Response to combination of retinoid and commercial tanning average initial dose of UV-B was 57 to 95 mJ. The aver- treatment per prospective study (n=17). Patients were grouped into categories depending on the percentage of reduction of Psoriasis Area and Severity Index age total doses of UV-A and UV-B per patient were 622.6 (PASI) score: PASI Ͻ25 (no change, or 0%-Ͻ25% reduction), PASI 25 J/cm2 and 29.9 J/cm2, respectively, for 9.5 weeks. (Ն25% reduction in PASI), PASI 50 (Ն50% reduction in PASI), PASI 75 Of the 17 patients, 14 patients completed the study. (Ն75% reduction in PASI), and PASI 90 (clearance, Ն90% reduction in PASI). Two patients were withdrawn within the first 4 weeks owing to noncompliance and personal issues. One patient was tients achieved a PASI and/or NPF score of 0 (1 at week withdrawn at week 11 due to an asthma exacerbation re- 6, 2 at week 8, and 1 at week 10) and were asked to dis- quiring systemic corticosteroid treatment (only data col- continue acitretin therapy and reduce light treatments lected prior to steroid treatment were used in our analysis). to twice per week. Each of these patients remained clear The PASI and NPF scores at weeks 2, 4, 6, 8, 10, at week 12. Two patients who continued to improve but and 12 were compared with baseline values (Figure 2). had not yet reached clearance opted to continue the com- The mean ± SD baseline and week 12 PASI scores were bination treatment after termination of the study. 10.9±4.5 and 2.1±2.5, respectively. The mean±SD base- Adverse event data were collected in both the retro- line and week 12 NPF scores were 20.5±3.0 and 4.4±4.9, spective and prospective studies (Table 4). In the retro- respectively. A clinically significant (PϽ.05) difference spective study, the most commonly reported adverse events from baseline was seen at 4 weeks and beyond in the NPF were cheilitis (17 patients [65%]) and dry skin (9 pa- score and 6 weeks and beyond in the PASI score. The over- tients [35%]); none reported “sunburn.” One patient ter- all mean percent reductions of PASI and NPF scores were minated treatment secondary to headaches, and another 78.6% and 79.0%, respectively. Patients who began with discontinued owing to hair loss. In the prospective study, moderate psoriasis experienced a 72.2% reduction in PASI the most common adverse effects were pruritus, dry skin, score, whereas those beginning with severe psoriasis had scaling, cheilitis, and a mildly erythematous, single- an average reduction of 85.9%. episode (grade 1) tanning bed burn. Nearly all adverse The patients were grouped according to percent re- events were mild and resolved at termination of therapy, duction in PASI (Figure 3). Clearance was considered with the exception of 1 case of mild hair loss. One serious to be a reduction in PASI score of at least 90%. Four pa- adverse event, an asthma exacerbation requiring hospi-

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 nation likely provides an additive beneficial effect. Both Table 4. Adverse Events Occurring More Than Once* the retrospective and prospective studies of re-TBUV showed much higher clearance rates than past studies of Medical Record Review Prospective Trial acitretin or tanning bed monotherapy. A meta-analysis Adverse Events (n = 26) (n = 17) of 12 studies of acitretin monotherapy reported that only Cheilitis 17 5 30.4% of patients with plaque-type psoriasis achieved Dry skin 9 6 clearance.16 Also, studies of TBUV alone showed only a Mild tanning burn 5 6 11,12 Itch 0 6 6% to 37% decrease in PASI. Scaling 1 5 When reviewed with the results reported by other ret- Triglyceride elevation 3 3 inoid and UV light combination therapy studies, re-TBUV Insomnia 0 3 fairs well. The clearance achieved in the present study is Dry eyes/conjunctivitis 3 0 lower than the 94% to 100% clearance reported in placebo- LFT elevation 0 2 controlled trials with acitretin plus PUVA therapy2,3 and Sore throat 0 2 4 Skin atrophy 2 0 acitretin plus bath PUVA therapy. However, the 79% re- Dry nose 2 0 duction in PASI achieved in the prospective phase of our GI disturbances 2 1 study compares favorably to 2 prospective studies of pa- Emotional lability 2 0 tients treated with acitretin plus UV-B that showed a 74% Dysesthesia 2 1 reduction at 12 weeks and 79% reduction at 8 weeks.17,18 Dry mouth 2 1 A significant benefit of combination therapies for pso- Alopecia 2 1 riasis is the reduction of adverse effects. We conjecture Abbreviations: GI, gastrointestinal; LFT, liver function test. that this will also be the case with re-TBUV. Acitretin ef- *Events reported once included scaling, erythematous rash, curly hair, ficacy and adverse effects are dose-dependent; thus, the dysuria, clouded sensorium, halitosis, asthma, myalgias/arthralgias, higher doses needed for adequate treatment in mono- epistaxis, nail dystrophy, nevus pigment, cough, ear tenderness, sinusitis, and moderate gastroenteritis. therapy may produce intolerable adverse effects for many patients.19,20 Because the acitretin dose in both the retrospective and prospective studies was lower than the av- talization for 24 hours and systemic corticosteroid therapy, erage monotherapy dose, adverse events should be much was believed to be unrelated to the acitretin and/or tan- lower.5 Only 3 patients of the 42 patients involved in both ning bed therapy. studies discontinued therapy due to adverse events. No patient had laboratory test results that were abnormal to Ͼ COMMENT the point that required termination ( 2 times the up- per limit of normal). Furthermore, in the prospective study The data from both the retrospective medical record re- all but 3 of the adverse events were reported as mild. Simi- view and prospective open trial provide strong evidence lar to other studies involving acitretin that show a slight that re-TBUV is an effective treatment for psoriasis. Pa- transient exacerbation before improvement,19 an initial tients in our population experienced a respectable re- increase in BSA occurred in many patients in the second duction in PASI score of 79% and excellent clearance rates week of evaluation, which was absent by week 4. How- of 47% to 52%. Patients who cleared before the prospec- ever, the overall PASI and NPF scores of week 2 showed tive trial termination were maintained clear for the re- a reduction from baseline due to a decrease in ery- mainder of the study with only 2 UV sessions per week thema, scaling, and induration. and without any further doses of acitretin. In the medi- Adverse events may also be associated with light cal record review, all patients who cleared were main- therapy. Adverse effects of UV-A, UV-B, and/or TBUV light tained clear for at least 2 months with 2 to 3 UV light include erythema, pruritus, phototoxic reactions, nau- treatments per week. Acitretin in these cases appears to sea, photoaging, increased lentigines, irregular pigmen- act as the “accelerator of clinical response,” which can tation, nonmelanoma, and perhaps melanoma skin can- be tapered off after maximal improvement while clear- cer.21,22 Both short- and long-term adverse effects are ance is maintained with low-frequency use of TBUV.15 believed to be lowered in retinoid and UV light combi- Reviewing response based on initial severity shows nation treatment as studies of re-PUVA and re–UV-B have that patients who initiated the prospective study with se- shown a reduction in dose and number of treatments vs vere psoriasis experienced higher rates of PASI reduc- their respective monotherapies.23 Although there is no tion than those with moderate psoriasis (85.9% vs 72.2%). standard for dosing therapy with tanning beds with which This unexpected finding indicates that re-TBUV effi- we could compare our values, the 2 studies involving tan- cacy might improve as the severity increases. Although ning bed monotherapy used a lower number and dura- a larger study would be needed to prove this point, it is tion of light treatments (3 treatments per week for 4-6 clear that the response we report is not because of a greater weeks vs 4-5 treatments per week for 12 weeks).11,12 It response in those with less severe disease. should be noted that the reduction in PASI score for these A principal benefit of any combination treatment is studies was modest. Only 1 known study has shown ben- increased efficacy over monotherapy. Comparison of our efit from UV-A alone.24 In this study, patients were ex- study to published studies of UV or acitretin mono- posed to a much higher levels of UV-A (1800-6988 J/cm2) therapy—or their combination therapies—cannot be made than the exposure dose in our study. because the populations are different. However, if large While the total dose of UV-A and UV-B is higher in differences are present it can be argued that the combi- our study than some past UV or UV-retinoid combina-

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 tion studies, comparison with UV doses commonly re- ning beds to be of that make and equipped with bulbs ceived in phototherapy clinics shows similar values. In that had a UV-B output of 4.6%.27 In our survey, we found the phototherapy units at the University of Utah Derma- that only 25% to 50% of the salons we tested were using tology Clinics, patients receiving 12 weeks of PUVA or Wolff beds with lamps emitting approximately 5% UV-B. re-PUVA may average a dose of 336 to 450 J/cm2. Aver- Many other bed types were available, and lamp UV-B out- ages of UV-B or re–UV-B therapy dose averages 23 to 31 put varied widely from 1% to 8%. Lamp type may also J/cm2 of UV-B (plus the accompanying 336 to 450 J/cm2 vary per country, since most tanning beds found in the of UV-A, since the “UV-B lamp” also emits a percentage United Kingdom are reported to have a percent UV-B of UV-A light). Initial UV-B dose in the University of Utah emission that ranges between 0.7% and 1.4%.28 In con- Dermatology Clinics phototherapy units is approxi- trast with a prior study29 that showed much lower ac- mately 100 mJ (50 seconds of exposure). In compari- tual percent UV-B output than the manufacturers re- son, patients in our prospective study started at 2 to 3 ported, our measurements indicated fairly equivalent and minutes for an average initial dose of 57 to 95 mJ of UV-B. constant percentages. Over the course of the present study, we had the Our selection of salons and tanning devices in the pro- opportunity to compare and contrast a new scoring sys- spective study, although adequate for a pilot study, limits tem, the NPF psoriasis score, to the more traditional a recommendation to wide implementation. These re- PASI score. Both scores showed similar overall reduc- sults, obtained in a small population under medical care, tion in psoriasis. The NPF score showed statistical sig- may not be reproduced by lamps or salons with different nificance of improvement relative to baseline at an ear- specifications. The prescribing physician who chooses this lier time point than the PASI score. This may be a treatment must be aware of the risks inherent to sending reflection of the unique components of the NPF score, patients to facilities with unknown dosimetry, intensity, which places more weight on induration, a less volatile and quality. It should be noted, however, that the medi- score, and less weight on erythema and scaling, which cal record review, which found similar efficacy and ad- fluctuate more with environmental factors. The NPF verse effects as the prospective study, used methodology score may prove to be a more meaningful measure of that closely mimics real-life decision making; patients were improvement because it includes a patient itch assess- asked to select Wolff tanning beds that had lamps similar ment and patient global evaluation, which takes into ac- to those that came with the original bed. All other vari- count factors such as psychological impact and discom- ables, such as the particular salon, cleanliness, safety, lamp fort due to psoriasis. Furthermore, the NPF score is not hours, and lamp type, were dependent on the patient’s se- dependent on total BSA because it evaluates the percent lection. Until re-TUVB can be tested in conditions simi- reduction in BSA from baseline; thus, it may ultimately lar to real life, this treatment should be reserved for areas be more useful than the PASI score in comparing pa- that do not have the option of prescription phototherapy tients with widely differing BSA or in patients with mild and to salons with well-trained technicians and good equip- to moderate psoriasis. This is the first indication that ment. Furthermore, these excellent results do not equate the NPF score may be an effective tool to assess psoria- to support of the commercial tanning bed industry for gen- sis in clinical trials. eralized use or for use for a particular “medical” condi- We recognize that our prospective study was lim- tion without physician’s guidance. ited in its lack of controls, absence of patient and ob- In conclusion, while there are limitations inherent server blinding, and study population that was fewer than to the retrospective and prospective studies, our results the hundreds of patients in phase 3 trials. A true compari- indicate that re-TBUV is a viable treatment for psoriasis. son between the various treatment modalities would re- This treatment is particularly applicable in settings in quire a double-blind, placebo-controlled trial, which would which PUVA or UV-B is unavailable owing to geo- be very costly and beyond the scope of our goal to assess graphic, cost, or other limitations. By combining acitre- the viability of the combination of acitretin and commer- tin therapy with commercial tanning, patients may cial tanning bed therapy. Hopefully, this report will prompt enjoy an available, efficacious, and cost-effective treat- additional studies that compare re-TBUV with placebo, ment of their psoriasis with an acceptable adverse effect monotherapies, and/or other retinoid and UV light com- profile. bination therapies. For physicians desiring to use re-TBUV for their pa- Accepted for publication November 20, 2002. tients with psoriasis, caution must be used in selecting This study was partially funded by a small educa- appropriate tanning salons and equipment. Tanning sa- tional grant from Roche Pharmaceuticals, Nutley, NJ, an un- lons differ vastly in bed type used, lamps used, fre- restricted gift from the Richard D. Movitz Foundation, Salt quency of changing lamps, number of hours on each lamp, Lake City, Utah, and the Department of Dermatology of the cleanliness, and the presence of knowledgeable and pro- University of Utah Health Sciences Center. The patients paid fessional staff.25 Tanning bed lamps progressively lose their all other expenses relating to treatment and care. There was intensity and may not be as effective after a significant no other funding for any aspect of the manuscript. There are amount of usage.26 In our prospective study, we at- no commercial associations, current or over the past 5 years, tempted to select salons with knowledgeable staff, evi- that might pose a conflict of interest. This includes consul- dence of greater cleanliness, and more safety precau- tant arrangements, stock or other equity ownership, patent tions than other salons we visited. We selected Wolff beds licensing arrangements, or payments for conducting or pub- with approximately 5% UV-B output based on a 1993 licizing the study. In addition, there are no similar associa- study in the United States that found most (81%) tan- tions with companies that make a competing product.

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 A portion of the information contained in this article 11. Fleischer AB Jr, Clark AR, Rapp SR, Reboussin DM, Feldman SR. Commercial was presented at the International Psoriasis Symposium, San tanning bed treatment is an effective psoriasis treatment: results from an un- controlled clinical trial. J Invest Dermatol. 1997;109:170-174. Francisco, Calif, June 22, 2001, and at the Western States 12. Turner RJ, Walshaw D, Diffey BL, Farr PM. A controlled study of ultraviolet A Medical Research Forum, Carmel, Calif, February 9, 2001. sunbed treatment of psoriasis. Br J Dermatol. 2000;143:957-963. We acknowledge Amandeep Chadha, MBBS, for his 13. Fredriksson T, Pettersson U. Severe psoriasis—oral therapy with a new reti- work in data collection and Melissa Weidner, RN, for her noid. Dermatologica. 1978;157:238-244. work as study coordinator 14. Krueger GG. New method being developed for assessing psoriasis. Natl Psoria- sis Found Forum. 1999;5:4-5. Corresponding author: Gerald G. Krueger, MD, Der- 15. Roenigk HH Jr. Acitretin combination therapy. J Am Acad Dermatol. 1999;41: matology 4B454, University of Utah Health Sciences Cen- S18-S21. ter, 50 N Medical Dr, Salt Lake City, UT 84132 (e-mail: 16. Geiger JM, Czarnetzki BM. Acitretin (Ro 10-1670, etretin): overall evaluation of [email protected]). clinical studies. Dermatologica. 1988;176:182-190. 17. Abel EA. Phototherapy: UVB and PUVA. Cutis. 1999;64:339-342. 18. Ruzicka T, Sommerburg C, Braun-Falco O, et al. Efficiency of acitretin in com- REFERENCES bination with UV-B in the treatment of severe psoriasis. Arch Dermatol. 1990; 126:482-486. 1. Lowe NJ, Prystowsky JH, Bourget T, Edelstein J, Nychay S, Armstrong R. Ac- 19. Ling MR. Acitretin: optimal dosing strategies. J Am Acad Dermatol. 1999;41: itretin plus UVB therapy for psoriasis: comparisons with placebo plus UVB and S13-S17. acitretin alone. J Am Acad Dermatol. 1991;24:591-594. 20. Goldfarb MT, Ellis CN, Gupta AK, Tincoff T, Hamilton TA, Voorhees JJ. Acitretin 2. Saurat JH, Geiger JM, Amblard P, et al. Randomized double-blind multicenter improves psoriasis in a dose-dependent fashion. J Am Acad Dermatol. 1988;18: study comparing acitretin-PUVA, etretinate-PUVA and placebo-PUVA in the treat- 655-662. ment of severe psoriasis. Dermatologica. 1988;177:218-224. 21. Spencer JM, Amonette RA. Indoor tanning: risks, benefits, and future trends. 3. Tanew A, Guggenbichler A, Honigsmann H, Geiger JM, Fritsch P. Photochemo- J Am Acad Dermatol. 1995;33:288-298. therapy for severe psoriasis without or in combination with acitretin: a random- 22. Westerdahl J, Olsson H, Masback A, et al. Use of sunbeds or sunlamps and ma- ized, double-blind comparison study. J Am Acad Dermatol. 1991;25:682-684. lignant melanoma in southern Sweden. Am J Epidemiol. 1994;140:691-699. 4. Lauharanta J, Geiger JM. A double-blind comparison of acitretin and etretinate 23. Lebwohl M. Acitretin in combination with UVB or PUVA. J Am Acad Dermatol. in combination with bath PUVA in the treatment of extensive psoriasis. Br J Der- 1999;41:S22-S24. matol. 1989;121:107-112. 24. Parrish JA. Treatment of psoriasis with long-wave ultraviolet light. Arch Derma- 5. Katz HI, Waalen J, Leach EE. Acitretin in psoriasis: an overview of adverse ef- tol. 1977;113:1525-1528. fects. J Am Acad Dermatol. 1999;41:S7-S12. 25. Culley CA, Mayer JA, Eckhardt L, et al. Compliance with federal and state legis- 6. Roenigk HH Jr. Combination and rotational therapy for psoriasis. In: Mailbach lation by indoor tanning facilities in San Diego. J Am Acad Dermatol. 2001;44: HRaH, ed. Psoriasis. 3rd ed. New York, NY: Marcel Dekker; 1998:5887-5592. 53-60. 7. Lowe NJ. Home ultraviolet phototherapy. Semin Dermatol. 1992;11:284-286. 26. Geis HP, Roy CR, Elliott G. Artificial suntanning: spectral irradiance and hazard 8. Turner RJ, Farr PM, Walshaw D. Many patients with psoriasis use sunbeds [let- evaluation of ultraviolet sources. Health Physics. 1986;50:691-703. ter]. BMJ. 1998;317:412. 27. Fleischer AB Jr, Lee WJ, Adams DP, Zanolli MD. Tanning facility compliance with 9. Boldeman C, Beitner H, Jansson B, Nilsson B, Ullen H. Sunbed use in relation to state and federal regulations in North Carolina: a poor performance. J Am Acad phenotype, erythema, sunscreen use and skin diseases: a questionnaire survey Dermatol. 1993;28:212-217. among Swedish adolescents. Br J Dermatol. 1996;135:712-716. 28. Diffey BL. Sunbeds: What Are They, Who Uses Them and What Are the Health 10. Fleischer AB Jr, Feldman SR, Rapp SR, Reboussin DM, Exum ML, Clark AR. Al- Effects? London, England: Health Education Authority; 1997. ternative therapies commonly used within a population of patients with psoria- 29. Bruyneel-Rapp F, Dorsey SB, Guin JD. The tanning salon: an area survey of equip- sis. Cutis. 1996;58:216-220. ment, procedures, and practices. J Am Acad Dermatol. 1988;18:1030-1038.

News and Notes

course on humanitarian assistance for dermatologists, intended to prepare dermatologists for participation in hu- A manitarian assistance projects under austere circumstances, will be offered in Bethesda, Md, from June 2 through June 6, 2003. The primary audience is federal dermatologists and residents, but the course is open to civilian dermatologists and residents with interest or experience in humanitarian assistance. The course is ideal for people who might volunteer to work with organizations that provide medical or humanitarian assistance and disaster relief. The course is offered under the auspices of the Department of Dermatology, Uniformed Services University of the Health Sciences, and the Center for Di- saster and Humanitarian Assistance Medicine. Up to 30 hours of AAD/AMA Level I CME will be awarded. The course has a limited enrollment. For more information, contact the course director, Scott A. Norton, MD, MPH, Dermatology Service, Walter Reed Army Medical Center, Washington, DC 20307; phone: (202) 782-9484; fax: (202) 782-9118; e-mail: [email protected].

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