What happened to phototherapy?
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Some say it’s underutilized or eclipsed by biologics, but it remains effective

Phototherapy, used to treat psoriasis for the past 100 years, is a modality with proven efficacy and an excellent safety profile. Yet it remains underutilized, in the opinion of many psoriasis experts. Ten years ago, a decline in its use was documented in the Journal of the American Academy of Dermatology (2002;46(4):557-59). The authors cited declining reimbursement rates and an increase in the price of ultraviolet (UV) light treatment units as two factors underlying the closing of many phototherapy centers in the late 1990s. Today, the advent of biologics as an alternative treatment for moderate to severe disease coupled with aggressive Medicare audits of phototherapy providers may also serve to suppress its use.

Medicare audits spark decline

“I’ve gotten calls from dermatologists who were audited by a Medicare committee that found something very trivial, and as a result asked the dermatologist to give all the money back from years of phototherapy,” said Mark G. Lebwohl, MD, professor and chair of dermatology at the Mount Sinai Hospital. “So I can tell you, there are dermatologists in this area who have stopped phototherapy because of that.” Dr. Lebwohl said the situation has gotten worse since the 2008 launch of the Recovery Audit Contractors program, which was designed to identify improper Medicare payments. “If you do the procedure over and over again, they’re looking for a way to get the money back. And that’s really hurt phototherapy.” [pagebreak]

Is expense a factor?

High costs to the physician also work against phototherapy, Dr. Lebwohl pointed out. “The units themselves are expensive, the rent on the space is costly, and reimbursement has not changed in quite a number of years,” he said.

Another leading phototherapy expert in a university setting takes a different view of the cost. “Financially, phototherapy is very much a positive element for the dermatology practice,” said John Koo, MD, professor of clinical dermatology at the University of California, San Francisco School of Medicine. “It can be performed by a physician extender; that’s very advantageous. Also, the phototherapy machine costs a fraction of what a laser used for cosmetic purposes would cost.”

Phototherapy vs. systemic options

Though the use of phototherapy has seen a slight increase since the “miserably low levels” found in the 2002 JAAD study, it remains underutilized, according to one of the study’s co-authors. Some dermatologists, like Steven R. Feldman, MD, PhD, professor of dermatology, pathology, and public health sciences at Wake Forest University School of Medicine and director of the Galderma Center for Dermatology Research, think that there’s very little light therapy being done because “more people are using systemic treatments: the toxic ones like methotrexate and cyclosporine, and the expensive ones like the biologics,” Dr. Feldman said. [pagebreak]

For patients whose psoriasis does not respond to topical medication, the choice between phototherapy and a systemic drug may rest on convenience. “It depends on whether the patient can come to the phototherapy center two to three times a week; that’s the main drawback — the need to put in time and effort and consistency,” said Henry W. Lim, MD, chair of the department of dermatology at Henry Ford Hospital.

UVB home therapy

Initial treatment of psoriasis with ultraviolet B (UVB) light therapy can require three to five phototherapy sessions per week, according to the AAD’s guidelines of care published in JAAD (2009;62(1):114-35). Once remission has been achieved, successful maintenance can require weekly visits on a long-term basis. This can impose hardships on patients with decreased mobility or those who live far from a phototherapy center. For those patients, purchasing UVB equipment for home use can be a convenient and cost-effective alternative, experts said. But several factors are limiting the number of patients who take advantage of it, including financial disincentives.

“Once the patient has been treated in the office setting and has improved tremendously, it’s ideal to switch the patient to home UVB to maintain the clearness,” Dr. Lim said. “The advantage of a home UVB unit, obviously, is that patients do not have to go to a treatment center to get the light treatment. The disadvantage is that the home treatment is not as intense as the light treatment in the clinic; for that reason, it is best used for maintenance.” The ideal candidate for home phototherapy is someone who is motivated and able to follow detailed instructions for its use, which may occur as often as six days a week, Dr. Lim said. Some units are equipped with a computer chip that disables the device after a specified number of treatments. “The challenge in the past was that patients would use it continuously for years without coming back to see a physician for evaluation,” he noted. “Now we can control and approve how many treatments the patient receives before having to call the office, and we can make sure the patient comes back to see the doctor periodically.” [pagebreak]

From the standpoint of malpractice risk, home UVB is “no different than prescribing medication,” Dr. Lim said. But it’s not a risk-free proposition. A patient who forgets to wear protective goggles at home could be blinded by the UVB treatment, Dr. Koo said. He recommends home UVB only for patients who have extensive experience with phototherapy in the physician’s office and know the proper safety precautions. 

A study of trends in home phototherapy adoption in the U.S., published in the Journal of Dermatological Treatment (2011;22(1):27-30), pointed to a few key factors that suppress the utilization of this treatment modality. “First, only 35 percent of dermatology residents we surveyed at a National Psoriasis Foundation chief residents meeting reported receiving any formal training on home phototherapy, and 73 percent had never prescribed a single home unit during their training,” said co-author Dr. Feldman. According to an analysis of records kept by a major supplier of phototherapy equipment, “only about half the patients who were prescribed a home phototherapy unit actually bought one.” Of those who were prescribed but did not purchase a unit, 76 percent said the reason was fear of high out-of-pocket expense (a home unit can exceed $2,000), and 43.6 percent said they opted for biologics instead — a choice that costs insurers far more than the one-time purchase of a home UVB unit.

Dr. Feldman noted that vague language in many insurance policies and patients’ uncertainty as to whether they will receive any reimbursement for a home UVB unit is enough to deter them from purchasing it. “This is a problem of awareness among insurers; phototherapy is not top-of-mind,” he said. “Insurers are not evil people, and they’re certainly not trying to lose money. By working with the insurers and educating them, it should be possible to make phototherapy more practical for patients.”

Physicans should also expect they may need to assist their patients with letters of request to insurance companies. [pagebreak]

Individual choice

Dr. Koo emphasized the efficacy and safety of phototherapy as the strongest arguments in its favor. “There’s a misconception that phototherapy doesn’t work as well as biologics do,” he said. “Biologics are not the most effective therapy. In the entire medical literature worldwide, there are only two treatments where 100 percent of the patients achieved a 75 percent improvement or better (i.e., PASI 75) in their Psoriasis Area Severity Index score after 12 weeks, and both of those treatments are phototherapies, RePUVA and Goeckerman therapies (Expert Opinions in Pharmacotherapy 2007;8(5):617-32).”

An interesting dichotomy currently exists. Some physicians, like Dr. Koo, felt that there were fewer prohibitive factors — particularly with insurance costs — associated with using phototherapy than there were with biologics. And while studies demonstrate the efficacy of phototherapy treatments, it may require a greater push by dermatologists to remove its stigma of not being as effective as other treatments, like biologics and other systemic options. While phototherapy is not going away, it may come down to a matter of individual choice and preference, i.e., that which is most effective and manageable for both physician and patient.