Skin type-based dosing narrowband UVB phototherapy for treatment of psoriasis
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Phototherapy with narrowband UVB (nbUVB) is a widely-used treatment for psoriasis. All published clinical trials on dosing of nbUVB used dosing schedules that were based on the minimal erythema dose (MED) of each patient. However, some dermatologists do not determine a MED prior to starting phototherapy, but instead dose according to the patient's skin phototype. While there are guidelines on skin type-based dosing, those are not validated in clinical trials. At Boston University Medical Center (BUMC), Dr Ruenger has successfully treated psoriasis patients with a skin type-based dosing protocol for several years and this protocol uses significantly higher doses when compared with the A A D guidelines. For this thesis, three different projects investigated various aspects of skin type-based dosing of nbUVB phototherapy. (1) In order to determine the current practice of phototherapy with nbUVB, we requested U.S. dermatologists to complete a 24-question online survey about dosing and safety of UVB-phototherapy, and found that most phototherapy- practicing dermatologists use skin type-based dosing only and that dosing protocols vary widely with 33% of survey participants using higher initial doses and dose increments than the AAD-guidelines. (2) In order to determine the effectiveness and safety of the "high-dose" skin type-based dosing protocol at BUMC, we conducted a five-year retrospective review. We found that the "high-dose" skin type-based dosing protocol at BUMC was highly effective and safe. (3) In order to compare the efficacy and safety of the BUMC "high-dose" protocol with the AAD-recommended "low-dose" protocol, we conducted a randomized, double-blind clinical trial with patients receiving nbUVB phototherapy for psoriasis. Eight patients have been enrolled; four achieved excellent treatment results and four did not. The trial is ongoing and has not been unblinded. It is therefore not known whether these strikingly different treatment responses are due to the different dosing protocols. Immunohistologically, we observed that epidermal proliferation and characteristics of T cell-infiltrate (CD4 > CD8, some Th17 cells and many regulatory T cells) did not change in a lesion that did not clinically improve within 4 weeks of nbUVB phototherapy. We conclude that skin type-based dosing nbUVB phototherapy is much preferred by US-based dermatologists despite the lack of validated guidelines, that the high-dose skin type-based dosing protocol of nbUVB phototherapy at BUMC is effective and safe, but that the optimal protocol for skin type-based dosing of nbUVB phototherapy for treatment of psoriasis remains to be determined.
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