How can a pediatric patient with psoriasis access UVA light therapy?

Accessing UVA Light Therapy for Pediatric Psoriasis

UVA light therapy (PUVA) can be accessed for pediatric psoriasis patients through dermatology specialty centers, but it should only be considered after narrowband UVB (NB-UVB) therapy has proven inadequate, as PUVA has limited supporting evidence in children and carries greater side effects. 1

Primary Recommendation: Start with NB-UVB, Not UVA

• NB-UVB phototherapy (311-313 nm wavelength) is the recommended first-line phototherapy option for moderate to severe pediatric plaque and guttate psoriasis (Strength B recommendation). 1
• NB-UVB is safer, more effective, and better tolerated than UVA-based therapies in children, with 60% of pediatric patients achieving ≥90% skin clearance after 12 weeks of twice-weekly treatment. 1, 2
• The American Academy of Dermatology explicitly states that NB-UVB should be prioritized over PUVA for younger patients (age <20 years) due to lower long-term carcinogenic risk. 3

When UVA (PUVA) May Be Considered

• PUVA therapy (psoralen plus UVA light) may be efficacious and well tolerated in children with psoriasis, but has only limited supporting evidence (Strength C recommendation, Level III evidence). 1
• PUVA should only be considered after NB-UVB has proven inadequately effective for chronic plaque psoriasis. 3
• PUVA is more effective for refractory psoriasis plaques that have not responded to UVB, but comes with greater side effects including the need for strict 24-hour protective eyewear use. 2, 4

How to Access Phototherapy

In-Office Treatment Options

• Phototherapy is typically administered at specialty psoriasis centers or dermatology clinics 2-3 times per week initially. 1, 3
• Treatment frequency can be decreased to 2 days per week upon improvement. 1
• Expect a delay in onset of efficacy (often >4 weeks), which requires patient and family counseling to prevent premature discontinuation. 1, 2

Home Phototherapy Equipment

• In-home UV light equipment is a viable alternative for pediatric patients who are geographically isolated or unable to consistently receive in-office phototherapy. 1
• This requires appropriate parent and patient education for safe administration. 1
• Home phototherapy can improve adherence, which is actually greater in pediatric patients than adults. 5

Natural Sunlight Alternative

• Some providers recommend natural sunlight in moderation in lieu of prescription home or in-office phototherapy when access is limited. 1, 2
• This is a practical consideration given logistical constraints many families face. 1

Treatment Protocol for PUVA (If Pursued)

• PUVA combines UVA light (320-400 nm) with psoralen, which can be administered topically or orally. 1
• Topical psoralen delivery (PUVA bath) has been used successfully in children ages 9-16 years with various skin conditions, limiting systemic UVA exposure while retaining efficacy. 6, 4
• Oral PUVA requires strict use of 24-hour protective eyewear between sessions, making it more burdensome than NB-UVB. 4

Critical Safety Considerations

• Male patients should use genital shields during any UV treatment. 2
• Proper eye protection (goggles) is essential during all phototherapy sessions. 2
• Regular monitoring by trained personnel is necessary, with monthly dermatologist examinations recommended during active treatment. 2
• Patients with multiple risk factors for melanoma, multiple non-melanoma skin cancers, or immunosuppression require careful screening before initiating any phototherapy. 2
• Only 16% of children show adverse effects from phototherapy, mostly mild erythema, with no severe adverse events reported in pediatric studies. 5, 7

Common Pitfalls to Avoid

• Do not start with PUVA as first-line phototherapy in children - always trial NB-UVB first unless there are specific contraindications. 3
• Do not discontinue therapy prematurely - adequate response assessment requires 20-30 treatments (typically 8-12 weeks at 2-3 times weekly). 3
• Avoid applying vitamin D analogs before phototherapy sessions, as they should be applied after treatment to avoid inactivation. 2
• Do not overlook the psychological burden of frequent clinic visits - consider home phototherapy equipment early for families with access barriers. 1