What does the guideline for PUVA (Psoralen and Ultraviolet A) therapy say?

British Association of Dermatologists Guidelines for PUVA Therapy (2015)

The British Association of Dermatologists and British Photodermatology Group guidelines provide comprehensive recommendations for the safe and effective use of PUVA therapy across multiple dermatological conditions, with specific guidance on when to use PUVA versus other treatment modalities to optimize patient outcomes while minimizing risks. 1

Disease-Specific Recommendations

Psoriasis

• All dermatology phototherapy units should offer both bath PUVA and oral PUVA for treating psoriasis (strength of recommendation B) 1
• PUVA should be offered before oral systemic therapy for chronic plaque psoriasis that hasn't responded adequately to other therapies, including narrowband UVB (strength of recommendation B) 1
• PUVA should be considered before biological therapy for chronic plaque psoriasis (strength of recommendation C) 1
• While occasionally appropriate as first-line phototherapy for especially thick/extensive plaque psoriasis, PUVA should usually only be considered after narrowband UVB has proven inadequately effective (strength of recommendation B) 1

Cutaneous T-Cell Lymphoma (CTCL)

• PUVA is the first-line treatment for plaque-stage CTCL (strength of recommendation B) 1
• Maintenance therapy may be considered to prevent relapse in quickly recurrent plaque-stage CTCL (strength of recommendation D) 1
• For patch-stage CTCL, narrowband UVB is as effective as PUVA and is the treatment of choice (strength of recommendation D) 1
• Combination therapy with PUVA and interferon or retinoids/rexinoids should be considered for early-stage mycosis fungoides if monotherapy response is slow (strength of recommendation B) 1

Other Dermatological Conditions

• Vitiligo: PUVA should only be considered for widespread vitiligo if narrowband UVB has not been adequately effective (strength of recommendation A) 1
• Atopic eczema: PUVA should be considered only if narrowband UVB has not been adequately effective (strength of recommendation D) 1
• Polymorphic light eruption (PLE): PUVA should be considered if UVB has failed or previously triggered the eruption, and before other systemic treatments (strength of recommendation D) 1
• Palmoplantar conditions:
  • Oral PUVA should be considered first-line for hyperkeratotic palmoplantar eczema (strength of recommendation D) 1
  • For palmoplantar psoriasis, either topical or oral psoralen with UVA is recommended (strength of recommendation C) 1
  • For palmoplantar pustulosis, oral PUVA is recommended (strength of recommendation C), and combination with oral retinoids should be considered unless contraindicated (strength of recommendation A) 1

Special Conditions Requiring Specialist Management

• Chronic actinic dermatitis (CAD): PUVA should be administered in specialist units with knowledge of the patient's action spectrum; may require inpatient supervision and topical/oral corticosteroid cover (strength of recommendation D) 1
• Solar urticaria (SU): PUVA can be considered after full assessment including definition of action spectrum; treatment should be in specialist units (strength of recommendation D) 1
• Erythropoietic protoporphyria (EPP): PUVA is rarely appropriate; narrowband UVB is the phototherapy of choice (strength of recommendation D) 1
• Actinic prurigo (AP): Narrowband UVB may be safer regarding carcinogenic risk, particularly in children, and should be considered before PUVA (strength of recommendation D) 1

Safety Recommendations and Monitoring

Pregnancy Considerations

• Female patients should avoid conception during PUVA therapy 1
• If pregnancy occurs despite this advice, PUVA should be discontinued (strength of recommendation D) 1

Recommended Audit Points

• Systems should be in place to record and review "burning" episodes, including: 1
  • Grading each episode
  • Reviewing episodes at 6-month intervals
  • Interpreting results in context of total treatments and patients treated

Documentation Requirements

• Clear documentation of painful erythema instances 1
• Staff training records for topical/oral PUVA therapy 1
• Provision of patient information leaflets 1
• Documentation of patient education regarding: 1
  • Skin carcinogenicity risks on sun-exposed skin
  • Eye protection requirements
  • UV protection following each oral PUVA treatment

Clinical Considerations

Minimum Phototoxic Dose (MPD)

• MPD should be established to avoid phototoxicity and ensure sufficient psoralen in the skin at the correct time 1
• This helps optimize treatment efficacy while minimizing adverse effects 1

Future Research Directions

• Randomized comparative studies comparing PUVA with biological therapy for chronic plaque psoriasis 1
• Studies investigating the effect of MPD measurement timing (72 vs 96 hours) on erythema episodes and treatment efficacy 1

Implementation Considerations

• For audit purposes, departments should review 20-50 cases to reduce variation in results and allow benchmarking between units 1
• Smaller departments may audit all cases seen in the preceding 12 months 1
• The guidelines provide evidence levels ranging from high-quality meta-analyses (1++) to expert opinion (4) to support recommendations 1