Ultraviolet Phototherapy

Over 50 conditions are treated with phototherapy. Psoriasis is the commonest single indication, with 50% to 75% of courses given being for this condition. A major advance in psoriasis treatment was the introduction, in the late 1980s, of narrowband UVB treatment through initial studies in the Netherlands and in the Dundee Photobiology Unit showing advantages over previously used broadband UVB treatments. However, PUVA remains important to treat some diseases unresponsive to narrowband UVB and for some individuals for whom narrowband UVB has not proved sufficient.

Ultraviolet A1 phototherapy (UVA1) is a more specialised form of phototherapy, initially used in the 1980s in Germany. The Photobiology Unit was the first UK centre to start offering this treatment (particularly useful in some relatively rare but often severe and otherwise hard to treat conditions such as morphoea) in 1996.

The PBU is regularly asked for advice on phototherapy from other centres throughout Scotland and from countries throughout the world. We continue to have an interest in new phototherapies and assessing their role as dermatological treatments.

The Dundee PBU has for decades been the centre in Scotland that most other centres looked to for guidance in use of the phototherapies. Following national audits of phototherapy, the National Managed Clinical Network for Phototherapy in Scotland (Photonet) was formed under a service agreement between NHS Tayside and the National Services Division (NSD) in 2002. This is a clinical governance network to help ensure (especially through annual audits) that the phototherapies are effectively and safely given in all of the 36 NHS phototherapy units across Scotland. The Network is based around national clinical standards; most centres also use treatment protocols offered by Photonet (and adapted from Dundee PBU treatment protocols). The Network is responsible for reporting to NSD - the commissioners of the service and NHS Health Improvement Scotland (HIS). One of the main features of the Network was the development of a centralised computer system (PhotoSys) to provide storage and retrieval facilities for patient treatment records.

This system assists with the ongoing national audit cycle for each of the phototherapy units in Scotland.

In addition it is used to identify patients with a heightened risk of developing skin cancer due to extensive exposure to ultraviolet sources, and these patients would then be invited to come for yearly skin screening and examination. Skin cancer risk of phototherapy is a key area of research focus.

The Network comprises of dermatologists, nurse phototherapists, photophysicists as well as management, administration and IT professionals. The administrative base of Photonet is in Perth. However, the initial development was by the Dundee PBU.

The Dundee phototherapy unit is a busy outpatient department within the photobiology area, treating between 100 and 120 patients a day with a variety of phototherapies (phototherapy area opening hours). The service is nurse-led and staffed by a mix of registered nurses and health care assistants. All nurse phototherapists have successfully completed the Photonet online educational module and attend regular educational updates. They also have ready access to senior dermatologists in Photobiology for advice on more complicated disease management. The treatment area was reburbished in 2011 to maximise the use of available space and to maintain compliance with Health & Safety and Infection Control policies.

Equipment for treatment options include:

• UVB narrow-band TL-01 cabinets x2
• UVA cabinet (for PUVA)
• UVA1 high-output metal halide Sellamed bed
• UVA1 high-output metal halide localised device
• UVA1 low-output fluorescent lamp cabinet 
• UVB and UVA (PUVA) localised hand/feet/scalp treatment

The Tayside service also has phototherapy units in Perth, St Andrews and Stracathro as well as a supervised home phototherapy service (see below). The Dundee unit is the centre for these services. Depending on the phototherapy regimen used patients usually undergo phototesting to establish their minimal erythema dose (MED) then attend two- to six- times weekly, often for 6- 8 weeks or more.
 
We are currently also investigating the clinical utility of patient self-directed phototherapy, following a successful pilot study, which should increase the availability and accessibilty of phototherapy for patients, and most importantly, provide appropriately selected patients with the opportunity for greater personal involvement in their management of chronic skin diseases.

Hospital supervised home phototherapy with narrowband UVB administered by the patient in their own home has been offered by the PBU-based phototherapy service since 1998. Attending the hospital for outpatient phototherapy can be impossible for some patients due to distance, or because of work and home commitments. For these patients, phototherapy as an inpatient was their only alternative to potentially toxic systemic therapies, but was not possible or appropriate for everyone.

There is an interest in home phototherapy elsewhere in Scotland, and we have on an individual patient basis supervised home phototherapy for some patients from other health board areas.

Home phototherapy equipment is fitted with eight UVB (TL-01) tubes. There are four lamps in the main panel of the unit and two in each door. The unit stands six feet tall and weighs around 56 kgs. When the doors are closed it measures only 60 cm wide, and 15 cm in depth. The unit can be moved to all sides on four wheels. As there are only three panels of lamps, the patient needs to treat each side of their body separately. The patient begins by facing the lamps, then turns to treat their left side, back, and right side. A safety bar was designed and manufactured to stop patients from standing too close to the unit. This foot bar ensures that the patient is standing the correct distance away from the lamps. The top bar was made to ensure that the doors are held open at the correct angle during the patient’s treatment.