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Psoriasis Excerpts

The use of combination therapy for the treatment of psoriasis

Sagransky M, Gustafson C, Feldman S

Skin and Aging. 2011.

Patients with psoriasis often experience limited results when undergoing monotherapy treatment. It is possible for successful clearance of the affected skin with just one treatment modality, but often, tolerance builds up over time and a notable decrease in efficacy is evident. In order to address this, combination therapy is often utilized. Combining phototherapy with topicals or systemics is an effective and safe therapeutic approach that minimizes adverse effects. In addition, narrowband phototherapy has also proven to be successful when combined with retinoids, methotrexate and others.

The safety and efficacy of biologics in psoriasis

Taylor A, West C, Feldman S

Skin and Aging. 2011.

There is much skepticism regarding the safety and efficacy of biologic therapies. Of course, avoiding adverse effects is a major goal when treating psoriasis, so when considering which treatment modality to utilize, weighing risk versus benefits is necessary. Side effects typically associated with the use of biologics include weight gain, headache, infection, increased risk of malignancy, and cardiovascular events, to name a few.

Social networking and the psoriasis patient

Noiles K, Thomas R

Psoriasis Forum. 2010;16(2):43-48.

Support groups are common for many disease states and psoriasis is no exception. Recent expansion of these communities to online networks has changed health care overall. Virtual groups of support have encouraged improved medication adherence and even serve as a means of collecting information that can be used in future research. One particular website,, has proven to accommodate not only the patients, but also the families and caregivers affected by psoriasis.

Treatment Comparison

Psoriasis Advance. 2011.

Many aspects must be taken into consideration when selecting a treatment modality for psoriasis. Frequency and method of dosing, length of therapy required, possible adverse effects and risks, and more must be kept in mind. Treating psoriasis with light therapy, proves to be a desirable option because of these considerations. Thrice weekly dosing for 12 weeks to achieve remission, accompanied by minimal side effects and risks in comparison to lengthier duration of therapy and even lengthier lists of adverse effects from other treatment modalities supports the use of phototherapy.

The reality of rising prescription prices and unfilled prescriptions

Blakeney S

The Dermatologist. 2017.

One major concern in treatment of psoriasis is the cost of the treatment method. Between 2009 and 2015, prices of dermatologic products increased by 401% for brand names and 279% for generics. Often, patients with psoriasis will need a combination of products, which will only increase their medication costs. Discovering and utilizing less expensive options is important in order to avoid patients leaving prescriptions unfilled.

Phototherapy more cost effective than biologics for psoriasis

Richards C

The Clinical Advisor. 2014.

“Prescribing phototherapy instead of biologics for psoriasis could save patients money.” For example, patients undergoing phototherapy accrue incremental costs under $4000, while patients prescribed biologic agents amass incremental fees over $8000, more than double the cost of phototherapy.

FDA issues boxed warning for efalizumab

Fiore K

Medpage Today. 2008.

Much like other biologics, efalizumab (Raptiva) carries a risk of infections that could be life-threatening, which comprises of progressive multifocal leukoencephalopathy (PML). Most biologics are immunosuppressive in order to decrease the flare ups associated with psoriasis, however this enhances the risk of contracting serious infection.

Skin cancer checks in psoriasis

Hilton L

Dermatology Times. 2018;39(9).

The risk of malignancy associated with psoriasis has created cause for concern as more awareness of comorbidities accompanying this disease has surfaced. While there is still inconsistent information on the topic, Doctor Megan Noe addresses the consistencies that are present. “Patients with psoriasis are at an increased risk of non-melanoma skin cancer: basal cell carcinoma and squamous cell carcinoma.” Dr. Noe urges patients, even with well controlled psoriasis, to undergo annual skin checks. For patients at increased risk and for those with a history of cancer, special consideration for treatment options is required. Dermatologists will tend to avoid biologics – as they typically also increase the risk of developing cancer – and select a treatment option such as phototherapy to avoid systemic effects. The risk of malignancy is something to be aware of but should not deter the use of effective treatment options.

Arthritis in psoriasis not as common as we once thought

Jesitus J

Dermatology Times. 2018.

Until a recent release of a meta-analysis, it was assumed that the prevalence of psoriatic arthritis (PsA) ranged between 5% and 42%. After compiling over 250 studies regarding the frequency of this complication, it was found that the estimated prevalence is closer to 20%, indicating that PsA is not as common as once believed. “Investigators observed decreasing proportion estimates as study population sizes increased.” Authors of this meta-analysis encourage physicians to screen patients with psoriasis for psoriatic arthritis.

Is it skin psoriasis or psoriatic arthritis?

Dermatology Times Staff

Dermatology Times. 2018.

A new report indicates that diagnostic tests for differentiating psoriasis from psoriatic arthritis now includes ultrasound. In patients with psoriatic arthritis, an ultrasound scan can identify inflammation in tendons, affected bones, and other structural abnormalities that are associated with the condition. On the contrary, if the aforementioned abnormalities are not present during the ultrasound, the patient is diagnosed with psoriasis instead of psoriatic arthritis.

Higher weight increases risk of psoriasis

Newswise. 2019.

Currently, it is known that there is a connection between increased body mass index and psoriasis, however, it is unknown which is the cause and which is the effect. “Higher BMI may contribute to increased inflammation of the skin, which can exacerbate psoriasis, but it could also be that psoriasis leads to a person being less physically active and thus gaining weight.” Research panels are working to better understand. To date, a team lead by Løset has found that for each whole number increase in BMI increases the risk of psoriasis by 9%, but there is still much left to clarify in regards to this relationship.

High rates of relapse after biologic discontinuation

Tumolo J

The Dermatologist. 2019.

Recently, another warning was added to the list for one medication to treat psoriasis; stopping ustekinumab (Stelara) may cause a relapse.

A review of adverse events in plaque psoriasis

Hilton L

Dermatology Times. 2018.

The newly released article written by Lisette Hilton investigates the possible adverse events associated with the use of biologic treatment options. Many first line treatment options have proven to have detrimental effects on patients who have long term and chronic treatment regimens. “The advent of biologics and small molecule inhibitors have revolutionized moderate-to-severe psoriasis treatment, but adverse events associated with these treatments can manifest early in patients.” While the introduction of biologic drugs has provided a revolutionary treatment option for psoriasis patients, usage must be carefully considered and closely monitored. “As the list of treatments for plaque psoriasis grows, so does the list of adverse events associated with biologic treatment.”

Effect of availability of at-home phototherapy on the use of systemic medications for psoriasis

Click J, Alabaster A, Postlethwaite D, Lide W

Photodermatol Photoimmunol Photomed. 2017;33:345-346. doi: 10.1111/phpp.12349

A study published in the journal of Photodermatology, Photoimmunology, & Photomedicine examines the impact of patients utilizing phototherapy treatments at home. The report investigated changes in prescription use of biologic therapies after the home phototherapy unit had been prescribed. Results of this study proved that the discontinuation rate of biologic agents were higher in patients who tried phototherapy treatments at home (24.9%) in comparison to those who did not start home phototherapy (10.6%). “This study showed that affordable home phototherapy coverage may lead to lower use of biologic agents… and reduce the cost of treating psoriasis.”

Initiating narrow-band UVB for the treatment of psoriasis

Do A, Koo J

Psoriasis Forum. 2004;10(1)

As with any form of treatment, the best regimen of phototherapy varies for each patient and is greatly dependent on skin type. “Narrow-band UVB is effective for the treatment of psoriasis.” The complexity of dosing should not be a barrier that prevents patients from receiving an extremely beneficial form of therapy. Therefore, Alice Do and John Koo compiled the most current protocols for prescribing narrow-band ultraviolet with the aim of providing confidence and support for dermatologists as they get more comfortable introducing this treatment modality to patient cases.

Diabetes risk in psoriasis increases with disease severity

Hilton L

Dermatology Times.2018.

Lisette Hilton’s article on the connection between psoriasis and diabetes states “psoriasis is an important predictor of diabetes risk and the more severe the disease, the higher the diabetes risk.” It was found through this study that individuals who suffer from severe forms of psoriasis have an increased risk of being diagnosed with type two diabetes (approximately 60% increase). It is believed that this correlation is a result of inflammatory cytokines being up-regulated in psoriasis; the identical inflammatory cytokines which lead to insulin resistance. Comparisons between patients with varying psoriasis body surface area were used to determine that “for every 10 percent increase in affected body surface area, diabetes risk rises by an additional 20 percent.”

Transition of patients with psoriasis from office-based phototherapy to nurse-supported home phototherapy: a pilot study

Matthews S, Simmer M, Williams L, Fishman P, Shors A

Journal of the Dermatology of Nurses’ Association. 2018;10(1):29-41. doi:10.1097/jdn.0000000000000374

Over hundreds of years, the utilization of ultraviolet light has proven to be a safe and effective treatment modality for psoriasis. Despite the positive results that are associated with phototherapy use, it has not been expanded as often as other treatment options due to frequent doctor’s office visits multiple times a week and misconceptions of the monetary burden. Transitioning patients from office-based to home-based treatments appeared to be favorable, according to this study. “Home phototherapy treatments, in particular, remove many of the patients’ financial and convenience barriers associated with phototherapy by providing treatment devices installed in patient living spaces.”

Malignancy rates in a large cohort of patients with systemically treated psoriasis in a managed care population

Asgari M, Ray G, Geier J, Quesenberry C

J Am Acad of Dermatol. 2016.

While biologic agents have become a popular treatment option for psoriasis, there are still many unknown dangers associated with this form of therapy. Negative side effects do not always become apparent during clinical trial periods, and therefore more thorough investigation takes place in a managed care setting to determine what potential harms patients are undertaking when using systemic treatments for psoriasis. A key example is the market withdrawal of the previously FDA approved drug, efalizumab. Five years after this drug had been released to the market, it was found that there was a significant increase in risk of progressive multifocal leukoencephalopathy.

Analysis of the cost effectiveness of home-based phototherapy with narrow-band UV-B radiation compared with biological drugs for the treatment of moderate to severe psoriasis

Vañó-Galván S, Gárate M, Fleta-Asín B, Hidalgo Á, Fernández-Guarino M, Bermejo T, Jaén P

Actas Dermosifiliogr. 2012;103(2):127-137.

Fundamental components that must be considered when selecting an appropriate line of therapy for treating psoriasis are effectiveness, efficiency, and cost. Each factor is taken into consideration when deciding between using home-based phototherapy and biologic drugs. This article states “the costs associated with effective treatment using biologic drugs in a single patient would provide effective home-based phototherapy for 9.1 patients.” In addition to this comment, it was also determined that “home phototherapy was more efficient than biologic therapy in patients with moderate to severe psoriasis. Home-based phototherapy represents a cost-effective treatment for patients.”

Narrowband UV-B phototherapy vs photochemotherapy in the treatment of chronic plaque-type psoriasis

Tanew A, Radakovic-Fijan S, Schemper M, Hönigsmann H

Arch of Dermatol. 1999:135(5):519-24. doi:10.1001/archderm.135.5.519

When determining whether to utilize phototherapy or photochemotherapy (PUVA) for the treatment of psoriasis, type and severity of psoriasis, patient age and health, and possible long term outcomes are all considered. This comparison study was conducted to define the benefits of each form of treatment and therefore which treatment option was better suited for patient needs. The article states “treatment with UV-B radiation is much easier to perform, requires less precautions to prevent acute adverse reactions, and seems to harbor a considerably lower carcinogenic potential than PUVA.” As a result, phototherapy is typically the first line treatment option in patients.

Narrowband UVB phototherapy for psoriasis: results with fixed increments by skin type (as opposed to percentage increments)

Halasz C

Photodermatol Photoimmunol & Photomed. 2009. doi:10.1111/j.1600-0781.1999.tb00061.x

Utilizing a conservative fixed increment regimen, in comparison to percentage increments, allows a successful clearing of the area affected with psoriasis. In addition, the risk of serious erythema due to light exposure is greatly reduced. It was also determined in this article that compared to traditional broad band phototherapy, narrow band phototherapy leads to increased and earlier clinical improvement; therefore, there is an increase in patient compliance with undergoing treatment sessions and a decrease in patient drop-out rates.

Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris

Walters I, Burack L, Coven T, Gilleaudeau P, Krueger J

J Am Acad Dermatol. 1999;40(6):893-900

This article compares the effectiveness of using narrow-band UVB in contrast to broadband UVB. Results were evaluated by means of Psoriasis Severity Index scores, as well as quantitative histologic measure. After the study was conducted, it was found that 81.8% of patients receiving narrow-band UVB exposure obtained clinical clearing of their psoriasis, while only 9.1% of patients noticed clearing after broadband UVB treatments. “[Narrow-band] UVB is superior to [broadband UVB] in reversing psoriasis at suberythemogenic doses.”

Comparison of psoralen-UVB and psoralen-UVA photochemotherapy in the treatment of psoriasis

Berker D, Sakuntabhai A, Diffey B, Matthews J, Farr P

J Am Acad Dermatol 1997;36:577-81

A study conducted by Berker and colleagues, examined the effectiveness of UVB and UVA phototherapy in conjunction with psoralen. Psoriasis clearance was possible with both forms of therapy; however, the most astounding result was the fewer required treatments to obtain clearance with the psoralen-UVB option. This study also showed that a lower portion of patients experienced psoriatic relapse if they had undergone psoralen-UVB rather than PUVA treatments. Findings from this study, as well as a similar comparison study, supports the use of psoralen in addition to narrowband UVB phototherapy to achieve the most “enhance[d] therapeutic response.”

Phototherapy of psoriasis of the scalp. Results in 21 patients treated with special portable ultraviolet rays lamp

Caccialanza M, Piccinno R, Cappio F, Rozza M, Mainardi L

G Ital Dermatol Venereol. 1989;124(11-12):LXI-LXV

A common misconception is that treatment of scalp psoriasis is difficult or nearly impossible due to the protective barrier that hair presents. Twenty-one patients tested portable ultraviolet light sources, utilizing the special comb designed to separate hair and provide light exposure to the previously protected skin. Among the 21 participants, all reported some form of improvement, with 11 noticing large improvement, and complete remission in 6 patients. “The source used was found to be efficacious especially in those forms of slight to medium psoriasis of the capillitium; it was handy and easy to use making it suitable for home use.”

Guidelines of care for the management of psoriasis and psoriatic arthritis

Menter A, Korman N, Elmets C, Feldman S, Gelfand J, Gordon K, Gottlieb A, Koo J, Lebwohl M, Lim H, Van Voorhees A, Beutner K, Bhushan R

J Am Acad Dermatol. 2010;62:114-135. 

Personalized medicine is a new and up-and-coming phenomenon that allows physicians to tailor treatment options to a patient’s needs. Psoriasis is a condition that benefits from personalized therapy, as no two cases are identical. A study by Menter, Korman, Elmets, et al. looked into the safety and efficacy of phototherapy, topical medications, systemic treatments, and combination therapy. They concluded that, “Although treatment options for psoriasis have expanded in recent years, UV light therapy remains an essential therapeutic option for patients with psoriasis. Phototherapy is efficacious, is cost-effective, and generally lacks the systemic immunosuppressive properties of both traditional and biologic systemic therapies.”

Combining biologic and phototherapy treatments for psoriasis: safety, efficacy, and patient acceptability

Farahnik B, Patel V, Beroukhim K, Zhu T, Abrouk M, Nakamura M, Singh R, Lee K, Bhutani T, Koo J

Psoriasis Targets and Therapy. 2016;6:105-111.

Most commonly, patients experience successful results from the use of phototherapy or biologic medications, however there are rare instances that patients do not respond well to a stand-alone treatment route. When this is the case, using the products together can produce more effective outcomes. Fortunately, combining the two therapy modalities presents very minimal risks. This allows patients to seek out an alternative treatment option when phototherapy or biologic drugs are not effective enough on their own, with narrowband UVB light therapy and biologics showing the most success in clearing psoriasis. Long-term effects of the combination have not yet been determined.

Incidence of skin cancers in 3867 patients treated with narrow-band ultraviolet B phototherapy

Hearn R, Kerr A, Rahim K, Ferguson J, Dawe R

Br J Dermatol. 2008;159:931-935.

Throughout the world, narrow-band ultraviolet B phototherapy (NB-UVB) has replaced broad-band ultraviolet B phototherapy for the treatment of psoriasis as it has proven to be more effective. Therefore, NB-UVB phototherapy has become a widely used therapy option. Because there is such limited data on the correlation between phototherapy and incidences of skin cancer, Hearn, Kerr, Rahim, et al. investigated. 3867 patients participated in the study and “no association was found between NB-UVB exposure alone (without psoralen-ultraviolet A phototherapy (PUVA)) and any skin cancer.”

Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomized controlled trial (PLUTO study)

Koek M, Sigurdsson V, van Weelden H, Steegmans P, Bruijnzeel-Koomen C, Buskens E

BMJ 2010;340:c1490  doi:

Phototherapy with ultraviolet B (UVB) light has proven to be a highly effective treatment option for patients with psoriasis. A study by Koek, Sigurdsson, van Weelden, et al. investigated the cost effectiveness of home phototherapy versus clinical phototherapy. The authors concluded that UVB light therapy treatments in an at-home setting did not cost more for a patient than receiving the equivalent treatments at an outpatient location. “Since both treatment strategies are equally effective and safe, and patients prefer treatment at home, we consider home phototherapy should be the primary treatment option for patients who are clinically eligible for phototherapy with ultraviolet B light.”

Recent trends in systemic psoriasis treatment costs

Beyer V, Wolverton S

Arch Dermatol. 2010;146(1):46-54. doi: 10.1001/archdermatol.2009.319.

Psoriasis is a prominent condition that impacts the lives of anywhere from 4.5 million to 7.5 million Americans. Treatment for this disease is pertinent and therefore finding a cost effective option is of the utmost importance, especially when the first treatment option was not effective for a patient. Beyer and Wolverton delved into the matter and discovered that the cost of traditional systemic therapy was much lower than the cost of biologics. The article states, “current trends demonstrate that systemic psoriasis therapy costs are increasing at a much higher rate compared with general inflation.” From 2000 to 2008, a 66% increase in costs was evident (range, -24% to +316%).

Sex-specific differences in the treatment of severe psoriasis

Hotard R, Feldman S, Fleischer A

J Am Acad Dermatol 2000;42:620-3, doi: 10.1067/mjd.2000.101596

Psoriasis is a condition that varies greatly from patient to patient; because of this a treatment option that is safe and effective, but is also able to be individualized is essential. Patient populations considered in this study by Hotard, Feldman and Fleischer were divided by gender.

While it was found that men are more likely to undergo more extensive and intensive treatments than women, overall “there is no notable difference in the treatment of men and women.” As of this 2000 article, the authors recommended the development of new and safe treatments for women of childbearing age.

Methotrexate plus narrowband UVB phototherapy versus narrowband UVB phototherapy alone in the treatment of plaque-type psoriasis: a randomized, placebo-controlled study

Asawanonda P, Nateetongrungsak Y

J Am Acad Dermatol 2006; 54:1013-8 doi:

The treatment options for psoriasis vary, and with each option there is an associated risk. Fortunately, all of the risks that have been found are associated with extended long-term use of the therapy. Due to this, combination therapy is often implemented. This allows a patient to experience accelerated improvement in their psoriasis, while being exposed to fewer doses of each modality. The study conducted by Aswanonda and Nateetongrungsak concluded, “Short-term adverse effects associated with this treatment combination are not different from when either treatment is used alone.”

Narrowband UV-B (TL-01) phototherapy vs oral 8-methoxypsoralen psoralen-UVA for the treatment of chronic plaque psoriasis

Markham T, Rogers S, Collins P

Arch Dermatol. 2003;139(3):325-328. doi:10.1001/archderm.139.3.325

In a study by Markham, Rogers and Collins, fifty-four patients with chronic plaque-type psoriasis were divided into two groups. One group was treated with photochemotherapy (oral 8-MOP PUVA) and the other group was treated with narrowband UV-B (TL-01) phototherapy; both groups received treatment until the psoriasis had completely cleared.  Upon conclusion of the study, it was found that the use of narrowband UV-B phototherapy is as effective for the treatment of chronic plaque psoriasis as the use of oral 8-MOP PUVA.

Targeted UV-B phototherapy for plaque-type psoriasis

Asawanonda P, Chingchai A, Torranin P

Arch Dermatol. 2006. doi: 10.1001/archderm.141.12.1542

While psoriasis can be widespread, it is most commonly localized to a small area on a patient’s body; this is when a targeted therapy option is effective. A study by Asawanonda, Chingchai, Torranin found that all fluences of UV-B showed there were clinical improvements and all treatments were well tolerated. In conclusion, “targeted UV-B phototherapy is a safe and efficacious treatment modality for localized psoriasis. Its value in other UV-B responsive conditions should be further investigated.”

Narrowband UV-B produces superior clinical and histopathological resolution of moderate-to-severe psoriasis in patients compared with broadband UV-B

Coven T, Burack L, Gilleaudeau R, Keogh M, Ozawa M, Krueger J

Arch Dermatol. 1997;133(12):1514-22. PMID: 9420535

The comparison between narrowband ultraviolet B (UV-B) light therapy and broadband UV-B showed clinical efficacy through the use of both treatments. However, “narrowband UV-B offers a significant therapeutic advantage over broadband UV-B in the treatment of psoriasis, with faster clearing and more complete disease resolution.” These results were determined from the study conducted by Coven, Burrack, Gilleaudeau, et al., where twenty-two patients suffering from moderate-to-severe plaque psoriasis were examined.

Phototherapy of psoriasis, a chronic inflammatory skin disease

Rácz E, Prens E

Adv Exp Med Biol. 2017;996:287-294. doi: 10.1007/978-3-319-56017-5_24.

“Phototherapy remains the only therapeutic option for certain patient groups where modification of the systemic immune reactions is contraindicated, such as by HIV, internal malignancy or pregnancy. UVB treatment is highly cost-effective, which is important in this age of increasing health care costs.”

Fumaric acid esters in combination with a 6-week course of narrow-band UVB provides for an accelerated response as compared to fumaric acid esters monotherapy in patients with moderate to severe plaque psoriasis: a randomized prospective clinical study

Tzaneva S, Geroldinger A, Trattner H, Tanew A

Br J Dermatol. 2017. doi: 10.1111/bjd.16106.

Patients that suffer from moderate to severe psoriasis have seen improvements with the use of fumaric acid esters (FAE); however, a slow onset of action has been noted. To improve this, adding the therapeutic option of narrowband ultraviolet B (NB UVB) light was effective. Results showed that adding the light therapy regimen to FAE solidified the response, and sped up the process. These outcomes also enhanced the patients’ quality of life.

Narrowband UVB treatment is highly effective and causes a strong reduction in the use of steroid and other creams in psoriasis patients in clinical practice

Foerster J, Boswell K, West J, Cameron H, Fleming C, Ibbotson S, Dawe R

PLoS One. 2017;12(8). doi: 10.1371/journal.pone.0181813

Foerster, Boswell, West, et al. studied the effectiveness of phototherapy when removing the use of steroid creams and others with the same purpose. “In conclusion, we show that NB-UVB treatment leads to both a major sustained improvement as well as significant reduction in topical treatments in approximately 75% of patients treated for psoriasis. The data support efforts to increase access for this treatment.”

Phototherapy with narrow-band UVB in adult guttate psoriasis: results and patient assessment

Fernández-Guarino M, Aboín-González S, Velázquez D, Barchino L, Cano N, Lázaro P

Dermatology. 2016;232(5):626-632. doi: 10.1159/000448918

Guttate psoriasis most commonly effects children and young adults, but can be present in adults as well. The use of narrowband ultraviolet B (NB-UVB) light therapy was studied in adult patients with acute guttate psoriasis (AGP). After the treatment, patients were asked to answer a questionnaire assessing the improvements and impression of the treatment. Overall, patients were satisfied with the light therapy option. “Phototherapy with NB-UVB appears to be a very good option for treatment of AGP because of the good results obtained and patient satisfaction.”

Ultraviolet B radiation therapy for psoriasis: pursuing the optimal regime

Matos T, Ling T, Sheth V

Clin Dermatol. 2016;34(5):587-593. doi: 10.1016/j.clindermatol.2016.05.008.

Possibly the oldest and most commonly used treatment option for psoriasis is phototherapy. “Phototherapy is an essential therapeutic option in the management of psoriasis, remaining a first-line treatment for many patients. It is efficacious, safe, and cost effective, making it one of the most preferable and convenient therapies for patients and avoids the issue of systemic immunosuppressive effects seen with biologic and traditional systemic therapies.”

The patient’s guide to psoriasis treatment. Part 1: UVB phototherapy

Singh R, Lee K, Jose M, Nakamura M, Ucmak D, Farahnik B, Abrouk M, Zhu T, Bhutani T, Liao W

Dermatol Ther (Heidelb). 2016;6(3):307-313. doi: 10.1007/s13555-016-0129-2

In an article by Singh, Lee, Jose, et al., it was concluded, “UVB phototherapy is a safe and effective treatment option for patients with psoriasis, eczema, vitiligo, and other photo-responsive disorders… With the appropriate safety and skin care precautions taken, phototherapy can help patients safely achieve rapid skin clearance and long-lasting remission.”

Ultraviolet B phototherapy for psoriasis: review of practical guidelines

Mehta D, Lim H

Am J Clin Dermatol. 2016;17(2):125-133. doi: 10.1007/s40257-016-0176-6.

Because psoriasis is such a prevalent and severe condition, treatment options vary widely to accommodate all patients. The use of topical agents and phototherapy are both common options for patients, and recently, the use of both modalities in conjunction with one another has proven to be safe and effective. The use of phototherapy in combination with biologic agents or phosphodiesterase inhibitors is still being investigated.

Treating psoriasis during pregnancy: safety and efficacy of treatments

Bangsgaard N, Rørbye C, Skov L

Am J Clin Dermatol. 2015;16(5):389-398. doi: 10.1007/s40257-015-0137-5.

Treating psoriasis is important as it impacts a person’s quality of life in a negative manner. Commonly, psoriasis begins to make an appearance during reproductive years; this makes treating expectant mothers a challenge. Because psoriasis is so unpredictable, going without treatment may not be an option for all women. Finding a safe and effective treatment for the mother and unborn child is a key goal.

Phototherapy in the elderly

Powell J, Gach J

Clin Exp Dermatol. 2015;40(6):605-610. doi: 10.1111/ced.12626.

Treating elderly patients who are diagnosed with psoriasis can pose many challenges. The skin of an elderly patient will not present in the same appearance, structure or physiology of a younger patient, and therefore it does not react the same to ultraviolet (UV) radiation. Elderly patients tend to be prescribed more medications so looking for alternative options of treatment that do not interact is also important. In a survey conducted by Powell and Gach, “phototherapy appears to be well-tolerated, safe and efficacious.”

Do interleukin inhibitors affect bodyweight?
The Dermatologist. 2018.

While the concept of biologic drugs is revolutionary and inventive, there are many adverse reactions that are unavoidable when using these medications. This article, published in July of 2018, addresses the weight gain associated with psoriasis treatment via tumor necrosis factor alpha inhibitors. Researchers determined through retrospective investigation that “infliximab (Remicade) increases bodyweight in patients with psoriasis.” Additional articles discuss the increased risk of serious infections, as well as other major side effects of infliximab.

Suicide risk among patients with psoriasis
The Dermatologist. 26(7). 2018.

According to a recent study, it was found that while patients with psoriasis did not have higher risk for suicide, there was an elevation in the frequency of mental health comorbidities in psoriasis patients. Individuals who are in direct contact with patients and who play a role in their care should keep a vigilant watch for signs of changes in mental health as well as physical health. “Healthcare professionals caring for patients with psoriasis should continue to monitor and tackle effectively the psychological needs of these individuals.”

Eczema Excerpts

Management of atopic dermatitis: safety and efficacy of phototherapy

Patrizi A, Raone B, Ravaioli G

Clin Cosmet Investig Dermatol. 2015;8:511-520.

Atopic dermatitis (AD), or eczema, is categorized as a chronic inflammatory skin condition that is present in all age groups. Frequent relapses and a negative impact on quality of life for patients are common outcomes of this disease. “Phototherapy represents an optimal resource for the treatment of AD.” Treatment with phototherapy can be combined with systemic drugs which allows a reduced dose of each modality.

Narrowband ultraviolet B (NBUVB) phototherapy in children with moderate-to-severe eczema: a comparative cohort study

Darné S, Leech S, Taylor A

Paediatric Dermatology. 2014.

Little research has been done to investigate the efficacy of phototherapy treatment in children. Darné, Leech, and Taylor looked at twenty-nine children using narrowband UVB (NB-UVB) phototherapy. In comparison to children that did not experience phototherapy, the treated population improved by 61% while the untreated population only improved 6%. “NB-UVB is clinically effective and improves quality of life in children with moderate-to-severe eczema.”

Safety and efficacy of phototherapy in the management of eczema

Patrizi A, Raone B, Ravaoli G

Adv Exp Med Biol. 2017;996:319-331.

First-line therapy options include topical emollients, such as corticosteroids and calcineurin inhibitors, and environmental measures. When this does prove to be effective, phototherapy is a back up treatment option. Ultraviolet A1 (UVA1) and narrow band ultraviolet B (NB-UVB) have proven to be the most effective phototherapy treatment options, respectively for acute and chronic eczema. However, no guidelines have been realized concerning the use of phototherapy for atopic dermatitis as no one light form has proven to be more effective over the others.

Medium-dose ultraviolet (UV) A1 vs. narrowband UVB phototherapy in atopic eczema: a randomized crossover study

Gambichler T, Othlinghaus N, Tomi N, Holland-Letz T, Boms S, Skrygan M, Altmeyer P, Kreuter A

Br J Dermatol. 2009;160(3):652-8.

A study was conducted to determine the efficacy of ultraviolet (UV) A1 and narrowband UVB (NB-UVB) phototherapies in patients with eczema. Twenty-eight patients were included in the study and while all participants showed improvements with both treatment modalities, there was not a significant difference between the two interventions. Therefore, both treatment lines may be considered comparably good, as both were efficient, effective and tolerable.

The treatment of severe atopic dermatitis in childhood with narrowband ultraviolet B phototherapy

Clayton T, Clark S, Turner D, Goulden V

Clin Exp Dermatol. 2007;32(1):28-33.

Phototherapy treatment in patients with atopic dermatitis has been shown to be effective, however there is not much literature supporting this. Clayton, Clark, Turner, et al. conducted a retrospective study of children who had received phototherapeutic care for atopic dermatitis. Based on this review, the authors found that the light treatments were effective in treating adolescents with severe eczema.

Local narrowband UVB phototherapy vs local PUVA in the treatment of chronic hand eczema

Sezer E, Etikan I

Photodermatol Photoimmunol Photomed. 2007;23(1):10-4.

Using PUVA for treating chronic hand eczema has been effective in the past; studies are now looking into the use of narrowband UVB to treat the same condition. Sezer and Etikan introduced fifteen patients with eczema to the different phototherapy treatment types in a nine-week study. The results proved that narrowband UVB phototherapy is just as effective as PUVA therapy to treat chronic hand eczema.

Narrowband ultraviolet B (UVB) phototherapy in children

Jury C, McHenry P, Burden A, Lever R, Bilsland D

Clin Exp Dermatol. 2006;31(2):196-9.

The use of narrowband ultraviolet B (UVB) phototherapy is well documented in adults, but the literature on its use in children is deficient, as well as information on long-term carcinogenic potential. Jury, McHenry, Burden, et al. conducted a study that treated 77 children suffering from psoriasis and eczema with narrowband UVB. Results concluded that the treatment was successful, therefore making phototherapy a useful and well-tolerated treatment for children.

Narrow-band ultraviolet B and broad-band ultraviolet A phototherapy in adult atopic eczema: a randomised controlled trial

Reynolds N, Franklin V, Gray J, Diffey B, Farr P

Lancet. 2001;357(9273):2012-6.

A randomised controlled trial conducted by Reynolds, Franklin, Gray, et al. looked into the treatment of eczema with narrow-band ultraviolet B phototherapy, as it has already been determined that phototherapy is safe and effective in the treatment of psoriasis. Results of the trial proved that the use of narrow-band UVB phototherapy was well-tolerated and effective in treating patients with moderate-to-severe eczema.

Phototherapy for atopic eczema with narrow-band UVB

Grundmann-Kollmann M, Behren S, Podda M, Peter R, Kaufmann R, Kerscher M

J Am Acad Dermatol. 1999;40:995-7.

In most cases, it is difficult to treat eczema and results often fall short of satisfactory. Using standard treatment options does not typically lead to desired results and using topical agents for extended periods of time can result in cutaneous and systemic side effects. In contrast, narrow-band UVB has proven to be effective in the reducition of atopic dermatitis after 3 weeks of treatment.

Experience with UVB phototherapy in children

Tay Y, Morelli J, Weston W

Pediatr Dermatol. 1996;13(5):406-9.

Over the course of four years, twenty patients were treated with ultraviolet B (UVB) phototherapy. The treatment for the patients showed effective results and a majority of the patients tolerated the treatment well, with no serious side effects reported. All patients in this study that had atopic dermatitis improved in their condition. “It appears that UVB photherapy is a valualbe and safe therapeutic option for selected children who do not respond to other treatments.”

Phototherapy for atopic dermatitis

Dogra S, Mahajan R

Indian Journal of Dermatology, Venereology and Leprology. 2015;81(1):10-15.

Dogra and Mahajan reviewed all available literature on the treatment of eczema in order to determine the most effective treatment option. “It may be deduced that among the various modalities administered as phototherapy, medium dose UVA1 and NB-UVB phototherapy are the most effective as observed in various randomized controlled trials and half-body paired comparon studies.”

Narrow band UVB phototherapy in dermatology

Dogra S, Amrinder J

Indian Journal of Dermatology, Venereology and Leprology. 2004;70(4):205-209.

Phototherapy has been used to treat photoresponsive skin conditions for centuries. “The general advantages of NB-UVB therapy over PUVA include safe use in children and pregnant women, no need for post-treatment eye protection, no drug induced nausea and no drug costs.” To date phototherapy has proved to be successful and safe in treating a majority, if not all photo-responsive conditions.

Ultraviolet phototherapy for cutaneous diseases: a concise review

Vangipuram R, Feldman S

Oral Dis. 2016;22(4):253-9.

“In dermatology ultraviolet (UV) phototherapy remains an established, lower cost, and often preferred option for many common skin conditions, despite the introduction of newer potent biologics.” The study conducted by Vangipuram and Feldman found that the use of phototherapy for many skin conditions is an effective option that holds a relatively benign side-effect profile.

Phototherapy in atopic dermatitis

Ortiz-Salvador J, Pérez-Ferriols A

Adv Exp Med Biol. 2017;996:279-286.

Current treatment options for atopic dermatitis include avoiding environmental triggers, specific skin care that targets the skin barrier defects, as well as anti-inflammatory therapy. When these options prove to be unsuccessful, treatment with systemic therapies or phototherapy are the next options, with many alternatives available for patient specific needs.

Benefits of controlled ultraviolet radiation in the treatment of dermatological diseases

Situm M, Bulat V, Majcen K, Dzapo A, Jezovita J

Coll Antropol. 2014;38(4):1249-53.

Behind traditional treatment modalities, phototherapy remains a safe and effective second-line option for treating photoresponsive conditions such as psoriasis, eczema and vitiligo. “Despite the introduction of numerous potent bioengineered systemic medications in the field of dermatology, phototherapy remains established, and often preferred, option for the most common dermatoses.

Atopic dermatitis linked to high disease burden
The Dermatologist. 2018

Patients who suffer from atopic dermatitis have reported much higher levels of dissatisfaction with their health and quality of life than other disease groups, comprised of chronic diseases such as diabetes, heart disease and high blood pressure. The symptoms associated with atopic dermatitis, including but not limited to itch, dryness or scaling, and others, lead to lifestyle changes and altered daily routines due to the severity of those symptoms. Because of this, it is recommended that doctors assess the quality of life of each patient to be able to find mental health disturbances.

Atopic dermatitis places heavy burden on patients
Dermatology Advisor. 2018.

It is not new information to researchers and patients alike that atopic dermatitis (AD) is detrimental to patient health; however, it may be surprising for patients without AD to discover just how much the disease burdens patients. This article investigated that burden and found that there are much higher rates of “having only fair/poor overall health, being somewhat/very dissatisfied with life, having lower weighted mean short-form 12 (SF-12) mental and physical health subscores, and having higher dermatology life quality index (DLQI) scores, compared to adults without AD.”

Cold weather prompts more health care utilization in atopic dermatitis

Jacobs S

Dermatology Advisor. 2018.

There are many aggravating factors that impact patients with atopic dermatitis (AD), one of which is weather. This is indicated by the number of patients that seek medical attention for their condition throughout the year. “Health care utilization in patients with AD was highest in the winter and spring. Outside temperature was the environmental variable with the strongest association with health care utilization.” Other environmental variables were also linked. “Associations between AD health care utilization and hours of cloud cover were generally positive, whereas hours of bright sunlight were generally inversely associated.”

Severe, active atopic eczema linked to increased cardiovascular risk
Dermatology Advisor. 2018.

Based on the study mentioned in this article, patients with atopic eczema are at a higher risk for cardiovascular disease including myocardial infarction, heart failure, and others. Researchers investigated whether this risk varied with the severity of the eczema and the condition over time. “Investigators concluded that targeting cardiovascular disease prevention strategies among patients with severe and/or predominantly active atopic eczema, including awareness of and screening for conventional cardiovascular risk factors by those providing clinical care, is warranted.”

Vitiligo Excerpts

Vitiligo in children

Kakourou T

World J Pediatr 2009;5(4):265-268. doi:10.1007/s12519-009-0050-1

Nearly seventy-six million people worldwide are affected by the acquired depigmentary disorder, vitiligo, with approximately half of those patients being diagnosed before reaching age 20, and an additional 25% being diagnosed before age 14, making this a fairly young condition. “Narrowband UVB (NB-UVB) phototherapy is considered as a safe and effective therapeutic option in the treatment of vitiligo in children.” Multiple studies have supported childhood exposure to NB-UVB treatments with results proving greater than 75% repigmentation of the vitiliginous skin.

New treatment could be ‘breakthrough’ for vitiligo

Gordon S

HealthDay. 2018

Recent implementation of ultraviolet-B light therapy in addition to the oral medication Xeljanz (tofacitinib) has resulted in “dramatic” outcomes in the study patients. While the initial findings of this theory provided what appear to be positive results, more studies need to be conducted to provide supplementary support of this combination of therapies. In addition, larger study groups should be researched to determine appropriate dosing, length of therapy, and the like. Regardless of the present lack of supporting evidence, there is great promise in providing UVB light therapy in partner with tofacitinib to clear vitiligo.

Dermatologists use novel combination therapy to restore skin color in vitiligo patients

Doctors and dermatologists alike have searched for an effective treatment option for vitiligo. A recent study conducted by a team of Yale doctors may have found just that. Utilizing an off-label use of the arthritis medication, tofacitinib, and narrow band ultraviolet B light therapy has resulted in promising and positive patient outcomes. By experimenting with this combination of therapies in recent studies, patients have noticed total or close to total restoration of skin color in affected areas. There is still much to learn about this revolutionary treatment option; however, what is known so far is assuring.

Home phototherapy in vitiligo

Mohammad T, Silpa-Archa N, Griffith J, Lim H, Hamzavi I

Photodermatol Photoimmunol Photomed. 2017;33:241-252. doi: 10.1111/phpp.12321

Until recently, the mainline treatment option for vitiligo (psoralen plus ultraviolet A) was also paired with negative and undesirable side effects until narrowband ultraviolet B therapy was introduced. Many added benefits come with this switch of therapeutic modality including a decrease in the number of side effects, larger increase in administration and improved color match. A large variety of phototherapy devices and light sources provide the opportunity to personalize the treatments to be patient specific and even home-based therapy. Based on this article, home phototherapy should be considered for treatment of vitiligo. “Not only is it safe and effective, but it eases many hardships associated with in-office phototherapy.”

Home based targeted ultraviolet B treatment of vitiligo – patient experience and clearance rates

Hornbeek L, Gourgouliatos Z


Previous studies have shown that home-based nontargeted phototherapy is safe and effective in treating vitiligo; however, little to no research has been done to determine the safety and effectiveness of targeted self-treatment. Hornbeek et al. found that home based targeted UVB phototherapy was effective in providing improved clearance of vitiligo. The smart interface and adjusting algorithm based on patient compliance was beneficial and added to patient ease of use, and improved safety. Skin repigmentation was similar to office-based treatments when the patient was compliant and adherent to the treatment schedule. The positive outcomes associated with this home-based targeted option makes it a favorable modality.

Narrow band UVB phototherapy in dermatology

Dogra S, Amrinder J

Indian Journal of Dermatology, Venereology and Leprology. 2004;70(4):205-209.

Phototherapy has been used to treat photoresponsive skin conditions for centuries. “In an important attempt to develop evidence-based guidelines for the treatment of vitiligo, NB-UVB therapy was recommended as the most effective and safest therapy for generalized vitiligo.” To date phototherapy has proved to be successful and safe in treating a majority, if not all photo-responsive conditions.

The vitiligo working group recommendations for narrowband ultraviolet B light phototherapy treatment of vitiligo

Mohammad T, Al-Jamal M, Hamzavi I, Harris J, Leone G, Cabrera R, Lim H, Pandya A, Esmat S

Journal of the American Academy of Dermatology. 2017;76(5):879-888.

Using light therapy to treat skin conditions, such as psoriasis, has become common practice. However, doctors have begun looking to expand the use of this technology by introducing the therapy option to patients with vitiligo. Based on research and analysis of data, professionals have started to recommend the administration of narrowband ultraviolet B phototherapy in vitiligo cases.

Randomized, parallel group trial comparing home-based phototherapy with institution-based 308 excimer lamp for the treatment of focal vitiligo vulgaris

Guan S, Theng C, Chang A

Journal of the American Academy of Dermatology. 2015;72(4):733-735.

In a study by Guan, Theng, and Chang, 44 patients were gathered and divided into two groups; one group received at-home phototherapy treatments via Daavlin Dermapal system, and one group received outpatient-setting treatments with an excimer lamp. Patients undergoing the home-based treatments were more compliant and because of this noticed more results. “This study demonstrated that with careful selection of the patients, home-based phototherapy can be as effective as institution-based treatment options.”

Phototherapy in vitiligo: assessing the compliance, response and patient’s perception about disease and treatment

Kandaswamy S, Akhtar N, Ravindran S, Prabhu S, Shenoi S

Indian J Dermatol. 2013;58(4):325.

Vitiligo, while not physically painful to the patient, does take a toll on the emotional and mental state. Phototherapy is a first line treatment option for patients and has to be given frequently, sometimes introducing a challenge to physicians and patients alike. At the conclusion of a retrospective survey, it was determined that patients with facial lesions or widespread areas of the condition are the most compliant groups of patients.

Narrowband ultraviolet B phototherapy in combination with other therapies for vitiligo: mechanisms and efficacies

Yazdani Abyaneh M, Griffith R, Falto-Aizpurua L, Nouri K

J Eur Acad Dermatol Venereol. 2014;28(12):1610-22.

Vitiligo is a skin disorder that is psychologically taxing to the patient. Not many treatment options have proven to be satisfactory, leading to the introduction of phototherapy, which has become the first line treatment option for vitiligo. Recently doctors have begun adding a topical agent to the therapeutic regimen to make the light treatments more effective and overall more successful in treating the condition.

Efficacy and safety of 308-nm monochromatic excimer lamp versus other phototherapy devices for vitiligo: a systematic review with meta-analysis

Lopes C, Trevisani V, Melnik T

Am J Clin Dermatol. 2016;17(1):23-32.

Comparison studies of the newest phototherapy treatment methods have been conducted to establish the best treatment method. To this date, there is no evidence to prove that one phototherapy option is greater than the other, therefore excimer lamps, excimer laser, and narrowband ultraviolet B options were all deemed effective and safe when aiming at the re-pigmentation of vitiligo lesions.

Narrowband UVB phototherapy in skin conditions beyond psoriasis

Gambichler T, Breuckmann F, Boms S, Altmeyer P, Kreuter A

J Am Acad Dermatol. 2005;52(4):660-70.

While narrowband UVB (NBUVB) has proven to be a safer and more effective option than broadband UVB and psoralen-UVA in treating psoriasis, there is not as much evidence in other skin conditions. A study was conducted to find more information on the use of NBUVB in non-psoriatic conditions. Results showed that “in view of its efficacy, benefit/risk profile, and costs, NBUVB may be considered the first-line photo(chemo)therapeutic option for moderately severe AD and widespread vitiligo.”

Vitiligo treatment in childhood: a state of the art review

Tamesis M, Morelli J

Pediatr Dermatol. 2010;27(5):437-45.

A study conducted by Tamesis and Morelli investigated the use of different treatment modalities for vitiligo. All ranges of treatment options were considered in this study, including topical creams, phototherapy, and combining genetic and immunologic factors to find the most effective option. Overall, “narrow-band ultraviolet B (UVB) has better overall re-pigmentation rates and safety profile than either topical or oral psoralens and ultraviolet A (PUVA).”

Ultraviolet phototherapy for cutaneous diseases: a concise review

Vangipuram R, Feldman S

Oral Dis. 2016;22(4):253-9.

“In dermatology, ultraviolet (UV) phototherapy remains an established, lower cost, and often preferred option for many common skin conditions, despite the introduction of newer potent biologics.” There is currently a large amount of information available on the use of phototherapy in psoriasis, but more studies and research are being done to find more data about the effects in vitiligo and eczema. Fortunately, phototherapy has historically proven to be an effective treatment option with a relatively benign side-effect profile.

Photo(chemo)therapy for vitiligo

Roelandts R

Photodermatol Photoimmunol Photomed. 2003;19(1):1-4.

Many therapeutic options have become available for treatment of vitiligo, however effects vary greatly, and results are often not satisfactory. Narrowband UVB is an efficient form of treatment as it provides positive therapeutic results and removes the requirement of a photosensitizing agent. These modalities have been in place since the ancient Egyptians, demonstrating the vast range of uses and remarkable success that comes as a result of the treatments.

Vitiligo as an aesthetic problem. Noninvasive therapeutic methods in vitiligo

Popko M, Kacalak-Rzepka A, Bielecka-Grzela S, Wesołowksa J, Klimowicz A, Maleska R

Ann Acad Med Stetin. 2011;57(3):23-7.

Treating vitiligo poses many challenges, as most often, complete therapeutic success is difficult to obtain. Utilizing non-invasive therapy options is ideal for patient comfort and compliance. Fortunately there are multiple options available to provide this form of treatment, such as PUVA- and UVB-therapy. These lines of therapy “are recognized as the most effective and most commonly used methods.”

Current state of vitiligo therapy – evidence-based analysis of the literature

Forschner T, Buchholtz S, Stockfleth E

J Dtsch Dermatol Ges. 2007;5(6):467-75.

Forschner, Buchholtz and Stockfleth conducted an analysis to compare the many therapeutic options for treating vitiligo. “For generalized vitiligo, phototherapy with UVB radiation is most effective with the fewest side effects.” However, “no single therapy for vitiligo can be regarded as the most effective as the success of each treatment modality depends on the type and location of vitiligo.”

Efficacy of targeted narrowband ultraviolet B therapy in vitiligo

Majid I

Indian Journal of Dermatology. 2014;59(5):485-489.

For patients with vitiligo, studies have proved phototherapy to be one of the most effective treatment options. Phototherapy devices that target a specific area are growing in popularity due to the countless advantages over subjecting a patient to a whole-body exposure. “Targeted NBUVB phototherapy seems to be an effective treatment option in localized vitiligo with a rapid onset of re-pigmentation seen as early as second week of treatment.”

Evaluation of narrow-band UVB phototherapy in 150 patients with vitiligo

Kumar Y, Rao G, Gopal K, Shanti G, Rao K

Indian J Dermatol Venereol Leprol. 2009;75(2):162-166.

Kumar, Rao, Gopal, et al. included 150 patients with vitiligo in a study to determine the safety and efficacy of narrowband ultraviolet B (NBUVB) phototherapy. In addition to good patient adherence and compliance, “our study, like all other studies, establishes that NBUVB therapy is an effective and safe modality to treat vitiligo of all age groups with cosmetically acceptable re-pigmentation.”

Narrow-band ultraviolet B is a useful and well-tolerated treatment for vitiligo

Scherschun L, Kim J, Lim H

J Am Acad Dermatol. 2001;44(6):999-1003.

While treating vitiligo can be challenging, efforts are being made to find a safe and effective method of treatment for the condition. A retrospective study by Scherschun, Kim, and Lim investigated the results of using narrow-band ultraviolet B phototherapy for patients with vitiligo. “In accordance with previous studies, this report indicated that narrow-band UVB is a useful and well-tolerated therapy for vitiligo.”

Narrow-band ultraviolet B as monotherapy and in combination with topical calcipotriol in the treatment of vitiligo

Arca E, Tastan H, Erbil A, Sezer E, Koç E, Kurumlu Z

J Dermatol 2006;33(5):338-43.

A randomized and comparative study performed by Arca, Tastan, Erbil, et al. looked into the safety and efficacy of narrowband UVB therapy as a solo therapy option and compared it to the combination of light therapy and topical calcipotriol. The research determined that NBUVB is safe and efficacious in the treatment of vitiligo, while adding the topical agent did not create an advantage to the therapy.

A comparative study on efficacy of UVA1 vs. narrow-band UVB phototherapy in the treatment of vitiligo

El-Zawahry B, Bassiouny D, Sobhi R, Abdel-Aziz E, Zaki N, Habib D, Shahin D

Photoderatol Photoimmunol Photomed. 2012;28(2):84-90.

“NB-UVB phototherapy remains to be an effective and safe therapeutic option in vitiligo. Response to UVA1 in vitiligo seems to be dose dependent and seems to be of limited value in treatment o vitiligo as a monotherapy.” This was concluded from a study of forty patients who were divided into groups and subjected to each type of light treatment options over a 12 week course of therapy.

No additional effect of topical calcipotriol on narrow-band UVB phototherapy in patients with generalized vitiligo

Ada S, Sahin S, Boztepe G, Karaduman A, Kölemen F

Photodermatol Photoimmunol Photomed. 2005;21(2):79-83.

While there is no true and absolute cure for vitiligo at this time, there are treatment options that prove to be successful in removing lesions. Main therapeutic routes available include phototherapy and topical calcipotriol. A study by Ada, Sahin, Boztepe, et al., determined that “narrow-band UVB phototherapy is effective by itself in vitiligo, and shows that adding topical calcipotriol does not improve treatment outcome.”

Home phototherapy in vitiligo

Mohammad T, Silpa-Archa N, Griffith J, Lim H, Hamzavi I

Photodermatol Photoimmunol Photomed. 2017;33(5):241-252.

Administration of narrowband ultraviolet B phototherapy has become the standard of care when treating a patient with vitiligo with the goal of re-pigmentation. “Home phototherapy is a safe and effective alternative to making phototherapy more accessible to patients. However, it is often underutilized due to lack of physician experience and comfort as well as misconceptions regarding its safety and efficacy.”

Narrowband ultraviolet B phototherapy in childhood vitiligo: evaluation of results in 28 patients

Percivalle S, Piccinno R, Caccialanza M, Forti S

Pediatr Dermatol. 2012;29(2):160-5.

The children included in this study were administered phototherapy treatments twice a week. As a result of this treatment, 50% of the children showed excellent improvements and 28.6% of the patients showed good response. No negative side effects were reported over the course of the approximately 10 month long study. This evaluation remained cohesive with other studies, as patients showed improvements with associated with good adherence.

Are narrow-band ultraviolet B home units a viable option for continuous or maintenance therapy of photoresponsive diseases?

Haykal K, DesGroseilliers J

J Cutan Med Surg. 2006;10(5): 234-40.

Phototherapy, due to its high rates of success and safety, is a popular option for treating many diseases that are photo-responsive. The struggle that this presents is the frequency of treatments. However, there is the option of performing phototherapy sessions at home. “Narrow-band ultraviolet B home phototherapy was found to be an effective form of maintenance therapy for photo-responsive diseases. It is safe and presents few side effects.”

Portable home phototherapy for vitiligo

Eleftheriadou V, Ezzedine K

Clin Dermatol. 2016;34(5):603-6.

Currently there is no cure for the most common depigmentation disorder, vitiligo. Many attempts at treating the condition in a noninvasive manner, for example, phototherapy, have proven to be successful. The next step is to introduce a phototherapy unit that allows and encourages more patient compliance. “Hand-held phototherapy devices might overcome the need to treat vitiligo in hospital-based phototherapy cabinets and allow early treatment at home that may enhance the likelihood of successful re-pigmentation.”

A cross-sectional, comparative study of home vs in-office NB-UVB phototherapy for vitiligo
2017. doi:10.1111/phpp.12326

Patients with vitiligo were gathered for a study to compare cost and treatment time of at- home versus clinical based phototherapy treatments. “Mean treatment time for the home group was 22 minutes vs 86 minutes for the in-office group. Annual cost for the home group was $4590 vs $21,270 for the in-office group. The cost of in-office phototherapy performed three times weekly exceeded the cost of home phototherapy after 3 months of treatment.” Home phototherapy has not been utilized in the past due to the misconception that it was inconvenient and expensive. As a result of this study, it is clear that phototherapy in the home may prove to be an exceptional option for vitiligo patients. This is supported by the fact that treatments at home are more convenient and are available at a lower cost to the patients. Both of these result in higher patient satisfaction, as well as improved results.

The efficacy of narrowband UVB treatment in pediatric vitiligo: a retrospective analysis of 26 cases

Yazīcī S, Günay B, Bülbül Baskan E, Aydogan K, Saricaoglu H, Tunali S

Turk J Med Sci. 2017;47:381-384. doi:10.3906/sag-1512-59

Narrowband ultraviolet B phototherapy has been used to manage and treat vitiligo for over 20 years after it was discovered that it was more effective than using topical psoralen and UVA treatments. The study by Yazici et al suggests that Nb UVB phototherapy seems to be a well-tolerated, effective, and safe method of treatment in the short term for pediatric patients, especially patients unresponsive to topical agents or with diffuse lesions.”


Is hyperhidrosis tied to psychiatric health?

Vogt C

The Dermatologist. 2019.

Screening patients who have been diagnosed with hyperhidrosis for psychiatric disorders such as ADD, depression, and anxiety has surfaced as an important step in the treatment process. “The study findings also demonstrated a correlation between mental health conditions and the number of body locations affected, but not for hyperhidrosis severity or body location.” Although discovering these connections between psychiatric disorders and hyperhidrosis has been beneficial in treating patients, additional research will be fundamental in clarifying the association between the conditions.

Efficacy and safety of tap water iontophoresis for palmoplantar hyperhidrosis

Akbar T, Saqib M, Fahim S, Nasir M, Nabi H

Journal of Pakistan Association of Dermatologists. 2013;23(3):304-309.

Upon conducting a small scale clinical trial, researchers were able to conclude that “tap water iontophoresis is a safe, effective, inexpensive and affordable treatment modality for palmoplantar hyperhidrosis.” They also concluded that quality of life of the patients undergoing treatment improved as well. All of these results support the use of tap water iontophoresis for the management of hyperhidrosis.

Efficacy of pulse directed current in tap water iontophoresis in treating primary palmar hyperhidrosis in pediatrics

Selim A, Ghafar M, Ali R, Abdel-Mageed S

International Journal of Therapies and Rehabilitation Research. 2015;4(2).

It is known that hyperhidrosis can severely impact a patient’s life, often deterring people from making social interactions and causing discomfort in general. This is especially true for adolescents who need social connections to mature properly. Treating hyperhidrosis in this patient population is important for this reason. Results of this particular study indicate that “tap water iontophoresis is useful and effective in reducing the sweat output in children with primary palmar hyperhidrosis.”

Treatment of primary palmar hyperhidrosis using glycopyrrolate iontophoresis: Intensity of electrical current used, efficacy and side effects

Leow M, Tey H

Indian Journal of Dermatology, Venereology & Leprology. 2017;83(3):387-388.

The goal of this study was to determine the optimum level of current intensity in treating hyperhidrosis. Utilizing between 7.5-8.0 mA proved to be the ideal level, as efficacy was highest while avoiding an increased incidence of side effects. Typically, patients undergoing this degree of treatment experienced roughly a week of palmar dryness before returning for treatment. Side effects included dry mouth and throat, and this was experienced by most patients. Current intensities above 8.0 mA resulted in higher frequency of side effects occurring, however the length of time patients experienced side effects was not impacted by the current intensity.

A study investigating patients’ experiences of hospital and home iontophoresis for hyperhidrosis

McAleer M, Collins P

Journal of Dermatology Treatment. 2014;25:342-344. doi:10.3109/09546634.2012.757287

Hyperhidrosis, a condition with many detrimental impacts on the lives of sufferers, affects nearly 10 million people in the US alone. To combat all of the negative side effects of the ailment, iontophoresis has been implemented in many mainline therapeutic treatment schedules. This study by McAleer and Collins determined that iontophoresis is a safe, effective, and inexpensive option in treating palmar, plantar or palmoplantar hyperhidrosis.

Long-term efficacy and side effects of tap water iontophoresis of palmoplantar hyperhidrosis – the usefulness of home therapy

Hölzle E, Alberti N

Dermatologica. 1987;175:126-135.

A 1987 study conducted in Germany that investigated the use of iontophoresis in hyperhidrosis cases remains a reliable source over thirty years later. “Tap water iontophoresis represents the most effective therapy in hyperhidrosis of palms or soles…With the use of an apparatus suitable for home treatment patients become independent of regular visits to the physician’s office or the clinic.”

Therapy: iontophoresis

Hölzle E

2011. doi:10.1007/978-3-642-02035-3_105.

Hyperhidrosis is a common condition that leaves patients with negative impacts on quality of life and causes emotional and psychological distress. Fortunately, treatment options have proven to be effective over many years of research. “It is out of question that tap water iontophoresis represents a very effective means of treatment in palmoplantar hyperhidrosis,” and “complete control of hyperhidrosis is normally achieved after 10-15 treatments” proving its effectiveness.

Iontophoresis for palmar and plantar hyperhidrosis

Pariser D, Ballard A

Dermatol Clin. 2014;32:491-494. doi:10.1016/j.det.2014.06.009

A common therapeutic modality of hyperhidrosis has been iontophoresis for more than 70 years. This is due to the safety and efficacy associated with the use of this option. This is evident in a study of 112 patients with palmar hyperhidrosis that resulted in an 81.2% reduction in sweating from baseline in just 8 treatments. With such promising results, “iontophoresis should not be overlooked as a primary treatment of palmar and plantar hyperhidrosis.”

Treatment of palmar hyperhidrosis using tap water iontophoresis: local experience

Chan L, Tang W, Lo K, Mok W, Ly C, Ip A

HKMJ 1999;5(2):191-194.

Hyperhidrosis is a common, yet dreadful condition that many people suffer from across the globe. Therefore, countless amounts of research have been conducted in order to find a solution to this hindersome condition. This Chinese study investigated the benefits of hyperhidrosis in patient cases and came to the conclusion “that tap water iontophoresis is a safe and useful treatment modality for palmar hyperhidrosis.”

The effectiveness of tap water iontophoresis for palmoplantar hyperhidrosis using a Monday, Wednesday, and Friday treatment regime.

Siah T, Hampton P

Dermatology Online Journal. 2013;19(3):14

A three-day-a-week treatment regimen of iontophoresis, as mentioned in the title, proved to be effective in treating and providing control in palmoplantar hyperhidrosis. In addition to this discovery, the study by Siah and Hampton also confirmed that “tap water iontophoresis is a safe and effective treatment of palmar and plantar hyperhidrosis when using this treatment schedule for 4 weeks.”

Efficacy of pulsed direct current in tap water iontophoresis in treating primary palmar hyperhidrosis in pediatrics

Selim A, Ghafar M, Ali R, Abdel-Mageed S

International Journal of Therapies and Rehabilitation Research. 2015;4:2

There is an abundance of literature available that covers iontophoresis in treatment of hyperhidrosis in adults, but much is lacking that focuses on the treatment regimen in the pediatric population. From the research that was completed by Selim, Ghafar, Ali, and Abdel, “it was concluded that using tap water iontophoresis is useful and effective in reducing the sweat output in children with primary palmar hyperhidrosis.”

Iontophoresis for palmoplantar hyperhidrosis

Kreyden O

Journal of Cosmetic Dermatology. 2004;3:211-214.

Patients who suffer from hyperhidrosis have previously had to accept their condition and live with the disease for the duration of their lives – even though it causes large amounts of stress – because the condition is harmless. This is no longer an issue for those patients thanks to tap water iontophoresis (TWI). “Without using invasive procedures, it is safe, well tolerated, efficient and low-priced.” As a result, TWI should be considered before all other treatment options.

Update on pediatric hyperhidrosis

Gordon J, Hill S

Dermatologic Therapy. 2013;26:452-461.

Using tap water iontophoresis (TWI) is not a new practice, as it has been used since the 1930s. Despite the fact that the mechanism of action of TWI is relatively unknown, there is great supporting evidence to prove that it is a safe and effective treatment option for the condition. This is true for adult and pediatric populations alike. “Reduction in sweat intensity and overall satisfaction has also been shown” after using TWI to treat hyperhidrosis.

Treatment of primary hyperhidrosis with tap water iontophoresis in pediatric patients: a retrospective analysis

Kacar S, Ozuguz P, Eroglu S, Polat S, Karaca S

Cutan Ocul Toxicol. 2014;33(4):313-316

“Tap water iontophoresis with direct current is a reliable and effective method of treatment for primary palmoplantoaxillary hyperhidrosis in both pediatric patients and adults.” Of all the participants in this 2014 study, only one did not show improvement using this treatment modality. Also, 89% of those participants reported a decrease in sweating of 50% or greater after iontophoresis treatment sessions.

Miscellaneous Excerpts

Maintenance PUVA therapy effective for mycosis fungoides

The Dermatologist. 2019.

In a 2019 study, it was concluded that “low-dose, low-frequency oral psoralen-UV-A treatment, followed by maintenance, appeared to be safe and effective and can be used to treat early-stage mycosis fungoides.” This study proved that PUVA treatment of mycosis fungoides can be highly effective and identified potential biomarkers for therapeutic response. It was also found that this treatment regimen could extend the disease-free period of remission.

PUVA or NBUVB for mycosis fungoides?

The Dermatologist. 2019.

Phototherapy is a very popular treatment option for mycosis fungoides, and with good reason. High levels of efficacy and low rates of adverse events make light therapy a viable treatment option for many patients. This article compares narrowband UVB to psoralen UVA phototherapy in treating mycosis fungoides. Findings state that either option could be used in treating early-stages of the disease.

Comparison of narrowband UV-B with psoralen-UV-A phototherapy for patients with early-stage mycosis fungoides: A systematic review and meta-analysis

Phan K, et al.

JAMA Dermatology. 2019.

Phan K, et al. compiled 7 studies in order to compare the efficacy of psoralen-UV-A and narrowband UV-B phototherapy. Overall, there were no significant differences between the two in terms of adverse effects and response rates were similar. “The findings suggest that narrowband UV-B is a viable and safe alternative to psoralen-UV-A for treatment of early-stage mycosis fungoides.”

Topical corticosteroids and the risk of diabetes mellitus: a nested case-control study in the Netherlands

van der Linden M, Penning-van Beest F, Nijsten T, Herings R

Drug Saf. 2009;32(6):527-37. doi:10.2165/00002018-200932060-00008.

While there is still much to study and learn about the relationship between topical corticosteroid exposure and risk of diabetes, more evidence is proving there is an association. Nearly 200,000 topical corticosteroid users were studied, of those patients, 2,212 developed diabetes. Through this study, researchers were able to determine that there is a 1.24-fold increased risk of developing diabetes associated with using topical corticosteroids, a factor that must be considered while treating patients – especially those patients who need intense skin therapy.

The effect of topical steroids on blood glucose profile in diabetic patients

Bahar I, Vinker S, Kaiserman I

J Clinic Experiment Ophthalmol. 2011;2:133. doi:10.4172/2155-9570.1000133

In 2011, researchers Bahar, Vinker, and Kaiserman investigated the correlation between the use of topical steroids and diabetic patients’ blood glucose profiles. 2,697 patients were included in the study. Results showed that fasting blood glucose levels and hemoglobin A1c increased by 11.6 mg/dl (from 145.8 ± 2.1 mg/dl to 157.4 ± 6.3 mg/dl) and by 0.6 (from 7.6+/-0.1% to 8.2+/-0.3%) respectively. These findings were statistically significant, proving that topical steroid use in patients with diabetes can increase blood glucose levels and disturb glycemic control.

Dermatophyte (tinea) infections

Goldstein A, Goldstein B


Topical corticosteroids are not recommended as first line treatment option for dermatophytes. Despite the possibility of accelerating healing time, the combined use of antifungal and corticosteroid products has an increased risk for topical corticosteroid-induced skin atrophy. Therefore, combining the products in treatment introduces patients to an unnecessary risk and side effect that can be avoided by using antifungal products singularly.

Tackling the impossible: psoriasis treatment algorithm guided by patients’ preferences

Tjahjono L, Cline A, Feldman S


Psoriasis presents many challenges when it comes to finding the best treatment option for each patient; due primarily to its varying presentation. Treatment modalities may not be effective for every psoriasis patient. However, UV-B phototherapy was declared the safest and most cost-effective treatment method in comparison to all other treatment techniques, making it an ideal candidate for a first-line treatment option.

What’s causing this teenager’s profusely sweaty palms?

Leung A, Barankin B


Hyperhidrosis, specifically palmar hyperhidrosis, can inadvertently impact quality of life by creating challenges with holding objects such as pens, causing metals to corrode just by holding them, and producing social anxiety associated with shaking hands. If untreated, hyperhidrosis can persist throughout life. There are a few treatment options available on the market today, however, iontophoresis is the leader with the fewest side effects.

Stigma another burden for many with psoriasis

Psoriasis, although not contagious, carries a negative social stigma. Patients with psoriasis are not only affected by the signs and symptoms immediately associated with the condition, but are also impacted by the psychological burden that comes with the skin disorder. Improving health literacy of the general public and patients alike is therefore just as important as the treatment of the disease.

Biologic linked to noninfectious pneumonia

In a recent study, it has been found that ustekinumab (Stelera ) is associated with noninfectious pneumonia. All cases reported during the eight-year span had serious outcomes and supported temporal association. Some of these cases occurred after just one dose of ustekinumab, leading to the additional warning for ustekinumab users regarding the elevated risk of developing noninfectious pneumonia.

Narrowband ultraviolet B phototherapy to clear and maintain clearance in patients with mycosis fungoides

Boztepe G, Sahin S, Ayhan m, Erkin G, Koleman F

J Am Acad Dermatol. 2005;53:242-6.

The use of narrowband ultraviolet B (UVB) phototherapy for mycosis fungoides (MF) has proven to be beneficial to some extent – when treatment is stopped, rapid recurrences are more common and therefore impact the efficacy of the treatment. Results of this study supported the use of narrowband UVB phototherapy in patients with MF, as well as suggesting narrowband UVB phototherapy as a maintenance treatment option for these patients.

Narrowband UVB phototherapy for early-stage mycosis fungoides

Gathers R, Scherschun l, Malick F, Fivenson D, Lim H

J Am Acad Dermatol. 2002;47:191-7.

The current list of uses for narrowband UVB phototherapy is in the process of expanding. As this treatment modality becomes more widely utilized, information about additional uses is growing. For example, narrowband UVB phototherapy has proven to be an effective, safe and easily administered treatment option for various dermatoses, such as mycosis fungoides.

Phototherapy for cutaneous T-cell lymphoma

Baron E, Stevens S

Dermatologic Therapy. 2003;16:303-310.

Phototherapy is a commonly used treatment option for multiple dermatologic conditions, and has been for decades. For diseases such as cutaneous T-cell lymphoma, disease state, extent of the disease, patient compliance and tolerability are all factors to be considered when selecting the specific light modality and in determining whether combination therapies are acceptable.

Patient reported priorities for comparative effectiveness research in psoriasis

Takeshita J, Armstrong A, Callis Duffin K, Robertson A, Attor R, Gelfand J

According to the authors of this article, “despite many new therapy options for psoriasis, phototherapy remains a preferred treatment among psoriasis patients.” Of all the patients surveyed, 91% reported their preferred method of treatment to be phototherapy, in either home- or office-based settings. In addition, patients that agreed to participate in comparative effectiveness studies predominantly wished to undergo home- versus office-based phototherapy comparisons instead of receiving biologic injections.

Does biologic therapy increase serious infection risk?

A recent study concluded that psoriasis patients receiving the biologic treatment infliximab (Remicade) are at a higher risk of contracting a serious infection that could lead to hospitalization, and even death, in comparison to patients receiving a non-biologic treatment alternative. Researchers concluded safer methods for treating psoriasis include exposure to topical and ultraviolet light therapies.

Phototherapy less utilized in practice, but still effective

Palmer W


For many unknown reasons, physicians are prescribing and utilizing phototherapy less in the treatment of psoriasis. Experienced doctors, such as dermatologist Abby Van Voorhees , are promoting and supporting the use of light therapy as it is a safe and effective treatment option, stating “phototherapy is becoming an underappreciated modality in the care of patients with psoriasis.” Dr. Van Voorhees also encourages residents to learn more about this therapeutic modality to truly understand “the benefits it provides to patients.”

Reduction of the erythema response to ultraviolet light by nonsteroidal anti-inflammatory agents

Edwards E, Horwitz S, Frost P

Arch Dermatol Res. 1982:272;263-267.

A study was performed to determine the effect of nonsteroidal anti-inflammatory agents (NSAIA) on erythemal response after exposure to ultraviolet B (UV-B) radiation. Results of this study proved the minimal dose of light required to produce erythema was increased by 240% when NSAIA were administered two hours before phototherapy exposure. This means that giving patients NSAIA before phototherapy sessions can improve patient erythema and tolerance for higher doses of UV-B.

Design and implementation of population-based specialty care programs

Botts S, Gee M, Chang C, Young I, Saito L, Lyman A

AJHP. 2017;74(18):1437-1439. dio:10.2146/ajhp161016

Kaiser Permanente, a nonprofit healthcare delivery system that offers care to 11.3 million members across the country, designed 3 specialty care programs targeted at specific, high-risk populations. One project, the Home Phototherapy Project, addressed those individuals affected by skin conditions such as psoriasis, eczema and vitiligo. “This [NB-UVB] treatment method was expected to address… patient concerns, reduce treatment costs, improve access, and reduce medication burden.” Through this project, over 2,000 patients received home phototherapy units. As a result, more and more patients were able to discontinue or reduce systemic and topical medication use and decrease potential adverse effects from those drugs.

Successful treatment of morphea with narrowband UVB (310-315 nm)-case report

Chiriac A, Brzezinski P, Pinteala T, Chiriac A, Solovan C, Foia L

Austin J Dermatolog. 2014;1(4):1018.

After experiencing no noticeable improvements and no favorable outcomes associated with using topical agents for multiple months to treat morphea, the patient mentioned in this article tried narrowband UVB therapy. After using the light therapy for 4 months, there were many favorable results including decreased thickness and less hyperpigmentation. “The immunomodulatory effects of UVB radiation can explain, at least in part, the beneficial effects observed in morphea.”

Narrowband ultraviolet B (311 nm, TL01) phototherapy in chronic ordinary urticaria

Aydogan K, Karadogan S, Tunali S, Saricaoglu H

International Journal of Dermatology. 2012;51:98-103

Chronic urticaria is defined by the widespread and remarkably itchy cutaneous hives, with flare ups lasting six weeks or longer with the individual lesions lasting less than 24 hours. Studies have been done that look into the utilization of UVA, UVB, and PUVA treatment options of urticaria. Results proved that narrowband UVB phototherapy was a more effective and well-tolerated alternative of treatment modality.

FDA approves Xolair ® (omalizumab) for people with chronic idiopathic urticaria (CIU), a form of chronic hives

Until a few years ago, the only approved therapy for chronic idiopathic urticaria was H1-antihistamines; however, this treatment was not providing sufficient responses in most patients. The FDA recently implemented Xolair (omalizumab) for patients 12 years and older who are still symptomatic even after using H1-antihistamines. Since this medication option is still new, there are side effects that occur, and will hopefully decrease as more information is obtained.

Psoralen plus ultraviolet A does not increase the risk of cataracts: a 25-year prospective study

Malanos D Stern R

J Am Acad Dermatol. 2007;57(2):231-7. doi:10.1016/j.jaad.2007.04.027

A common fear associated with the use of psoralen plus ultraviolet A (PUVA) therapy is the increased risk of unwanted side effects, for example cataracts. A study conducted by Malanos and Stern evaluated the aforementioned risk with promising results. Based on the cohort studied and the data collected from a 24 year time span, it was determined that “increasing exposure to PUVA does not increase cataract risk among persons using eye protection.”

Moderate exercise and bright light treatment in overweight and obese individuals

Dunai A, Novak M, Chung S, Kayumov L, Keszei A, Levitan R, Shapiro C

Obesity. 2007;15(7):1749-1757.

“This randomized, controlled study is the first to show that bright light treatment during exercise impacted body composition by significantly reducing body fat after only a 6-week period.” Although the results of this study did not reach significance, there was evidence to prove that body fat composition was reduced with the implementation of bright light during exercise, despite the fact that body weight was not necessarily changed by the presence of light.

Infliximab is associated with an increased risk of serious infection in patients with psoriasis in the United Kingdom and Republic of Ireland: results from the British Association of Dermatologists Biologic Interventions Register (BADBIR)

Yiu Z, Ashcroft D, Evans I, McElhone K, Lunt M, Smith C, Walton S, Murphy R, Reynolds N, Ormerod A, Griffiths C, Warren R


Investigations of the use of the monoclonal antibody, infliximab (Remicade), that targets tumor-necrosis factor alpha in the treatment of psoriasis, are outlined in this article. Based on the results of the study, it was found that infliximab is successful in clearing psoriasis; however, negative side-effects are associated with its use. The most disconcerting is the large increase in risk of serious infection that goes hand-in-hand with the use of this biologic drug in comparison to alternative treatment options (ie. non-biologics, methotrexate only therapy regimens).

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