Approximately five million Americans suffer from psoriasis, with about 150,000 new cases diagnosed each year. About two out of every hundred people in the U.S. are diagnosed with vitiligo. Both are chronic skin conditions that are notoriously difficult to treat, frustrating both patients and physicians.
A promising new, drug-free treatment for chronic skin conditions
People who suffer from these skin diseases, as well as atopic dermatitis (eczema) and parapsoriasis, have often run the gamut of treatments and are sometimes told, "There's nothing more we can do for you."
A new treatment, however, is showing extremely promising results in the battle against these persistent diseases. Phototherapy, using narrow-band ultraviolet-B (UVB) waves, has had great success in keeping these conditions at bay. It is leading-edge technology that has been available in Europe for about 10 years and is now making its way in the United States.
Narrow-band UVB phototherapy is a highly effective therapy that does not involve any type of medication, so there are no drug-to-drug interactions or medicinal side effects about which to be concerned. This treatment is ideal for patients who are taking multiple medicines and don't want to have interactions or are leery of taking long-term medicines.
It is mainly used in the treatment of psoriasis, vitiligo, atopic dermatitis and parapsoriasis. Up to 30 percent of psoriasis sufferers also exhibit symptoms of arthritis; often the arthritis symptoms improve when the patient's skin improves. With this new treatment, patients are clearing up at a surprising rate.
My clinic, which is the only one in Minnesota that has both full-body and hand-and-foot phototherapy units, has administered well over 2,000 treatments since January 2002. The results have been phenomenal.
The phototherapy unit is basically a light booth, very similar to a tanning booth, completely enclosed with light bulbs going all the way around. Patients, wearing protective eyewear, stand in the booth for anywhere from one to 15 minutes. Each time a patient comes into the clinic, the amount of exposure is increased by just a few seconds.
Psoriasis patients will generally see suppressive results with 20 to 30 treatments, however with more than 30 treatments the results tend to be more remissive. Sometimes remission will last several months, but there have been reports of remission lasting several years with this treatment.
This wavelength of light, the UVB wavelength, penetrates in a much more shallow manner than previously-used UVA waves, which penetrate much deeper and are associated with a long-term increased risk of developing skin cancer. Because of that, many physicians are wary of committing patients to extensive UVA therapy. The UVB wavelength does not carry the same risks.
Not only are UVB waves more effective and less risky than UVA waves, but narrow-band UVB waves are superior to broad-band UVB waves, which were also previously used to treat these skin conditions. Broad-band waves cover a spectrum of about 30 nanometers. It was eventually discovered that only three of the 30, or 10 percent of the spectrum, were effective at treating skin conditions. Because much of the broad-band light spectrum was not effective, the treatments were not as effective, causing patients to be treated more often and for a longer period of time. A special bulb was then designed that emits only the effective portion of that wavelength, decreasing the length of treatment and increasing the positive results.
Before this treatment, common ways to treat these skin conditions included topical treatments, phototherapy using UVA or broad-band UVB wavelengths and oral medication. The oral medication used to treat psoriasis usually contains fairly strong immuno-suppressive agents that have their own set of toxicities, such as kidney and liver toxicities. In fact, Methotrexate is a common anti-cancer medicine, and Cyclosporine is used in patients with organ transplants to suppress the immune system so they will not reject organs. So these are fairly potent systemic medications. They work very well, but they need to be used appropriately and carefully.
Other treatments used for vitiligo include topical creams with corticosteroids, psoralen in combination with UVA light (PUVA) and in rare cases, skin grafting. Creams containing corticosteroids have been shown to be effective with small areas of vitiligo. PUVA requires at least a year of twice weekly treatments for about a 50 to 70 percent chance of improvement, and even then it is not very effective in returning pigment to hands and feet.
While phototherapy is proving to be an effective, less invasive and less time-consuming treatment on its own, sometimes the results are enhanced when used in combination with these other treatment methods.
The vast majority of patients are extremely pleased with the results from narrow-band UVB phototherapy treatment. Most patients who suffer from psoriasis and vitiligo have been through several types of treatments, and they are always hungry for something new. And this is something both new and effective, so they are both pleased with the results. They are also pleased that their doctors were aware enough to send them in for phototherapy treatment.
Russell C., a patient who has suffered from vitiligo for more than 15 years, has chocolate-brown skin and exhibited porcelain-white patches on his cheeks, eyelids and arms. He was very frustrated because everywhere he went people asked him what was wrong with his skin. Finally, after 15 years of unsuccessful treatment, he went through a course of narrow-band phototherapy. Since receiving the therapy, he has completely re-pigmented his face and he's absolutely delighted. For him, it was life changing.
As far as psoriasis patients, we've had several patients that have had great success with this therapy. These patients have tried all kinds of topical and systemic medications, and for some, this is the first time they've been clear in 10 or 15 years. One patient, John S., said he lives near one of the Minneapolis lakes, and this is the first time in 15 years that his legs have been clear enough that he can actually wear shorts and walk around the lake without embarrassment.
We also have several children with vitiligo who are at the age where they are teased incessantly at school about their skin condition, and they have responded very well to the treatment and are delighted with the results. Phototherapy treatment is completely safe and can be used on children old enough to tolerate standing in a light box, usually children over the age of 4.
One drawback to this treatment is that it is not always covered by insurance. It is covered 80 to 90 percent of the time for the treatment of psoriasis, and about 60 percent of the time for vitiligo. Another minor drawback is that it is a bit labor intensive. Patients need a minimum of two treatments per week, and optimally three treatments per week, so they need to come into the office two to three times per week. The average treatment number is anywhere from 20 to 40 sessions, so it's about a 10-week commitment.
This type of treatment needs to be administered by someone knowledgeable in the use of phototherapy, because improper settings can cause a mild phototoxic, sunburn-type reaction.
While this treatment has shown amazing results, the therapy is not perfect - for psoriasis it works about 90 percent of the time, for vitiligo about 60 to 70 percent of the time and for atopic dermatitis it is effective about 80 percent of the time. So by no means is it perfect, but as narrow-band UVB phototherapy treatment becomes more widely known, physicians will be able to offer new hope to patients that have long suffered from these uncomfortable, embarrassing and sometimes painful skin conditions.
Charles E. Crutchfield, III, M.D. is a clinical assistant professor of dermatology at the University of Minnesota and runs his own practice, Crutchfield Dermatology in Eagan
# # #