Joint Phototherapy Guidelines Week 6: PUVA Overview, Risks and Recommendations

Recently, the American Academy of Dermatology and the National Psoriasis Foundation released guidelines of care for the management and treatment of psoriasis with phototherapy. Over the next few weeks, we’ll examine the recommendations and share information about the significance for your practice and patients.

Week 1: Treating with Narrow Band UVB

Week 2: Home Narrow Band UVB

Week 3: Combination Therapy with Narrow Band UVB

Week 4: Risks of Narrow Band UVB

Week 5: Broadband UVB Overview, Risks & Recommendations

Week 6: PUVA Overview, Risks & Recommendations

Week 7: Summary

PUVA Overview & Risks:

PUVA combines a Psoralen drug (typically Methoxsalen in North America) with exposure to ultraviolet light A (UVA). Psoralens make the body very sensitive to UVA rays and comes in oral or topical formulations.

The guidelines consider Topical PUVA “best suited for the treatment of localized psoriasis and is recommended in particular for palmoplantar disease.” It can be mixed with an emollient and applied 20 minutes before exposure or mixed with water for the soaking of hands and feet. Soaking is recommended for 30 minutes before UVA exposure.

In Bath PUVA, the psoralen is mixed with water to allow soaking of affected areas before exposure to light. Although this method is recognized as less effective than oral PUVA, it does have fewer side effects and requires a lower cumulative dose of UVA light to obtain clearance. Because of this, some patients may prefer bath PUVA over oral PUVA. However, there are some associated barriers. Practitioners may have trouble obtaining reimbursements from insurance companies and the resources needed for the maintenance and operation of a bath can be substantial.

Oral PUVA is very effective in treating psoriasis and, once clearance is obtained, maintenance therapy is recommended. Combination therapy with PUVA and an oral retinoid, such as acitretin, is shown to increase efficacy of either treatment alone. Risks associated with oral PUVA may include phototoxicity, nausea, pruritis, photo-onycholysis, and melanonychia. “Lentigines and photocarcinogenesis (primarily squamous cell carcinoma) are adverse effects of long term oral PUVA exposure.” To read more about the risks related to the use of PUVA, please download a copy of the joint phototherapy guidelines here.

PUVA Recommendations:

The guidelines find that Topical PUVA is superior to localized NB-UVB light when treating adults with localized plaque psoriasis, especially palmoplantar psoriasis and palmoplantar pustular psoriasis. Oral PUVA is recommended for the treatment of psoriasis in adults and Bath PUVA is recommended for the treatment of moderate to severe plaque psoriasis in adults.