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Gelfand JM, Armstrong AW, Lim HW, Feldman SR, Johnson SM, Claiborne WCC, Kalb RE, Jakus J, Mangold AR, Flowers RH, Bhutani T, Durkin JR, Bagel J, Fretzin S, Sheehan MP, Krell J, Reeder M, Kaffenberger J, Kartono F, Takeshita J, Bridges AM, Fielding E, Nehal US, Schaecher KL, Howard LM, Eakin GS, Báez S, Bishop BE, Fitzsimmons RC, Papadopoulos M, Song WB, Linn KA, Hubbard RA, Shin DB, Callis Duffin K. Home- vs Office-Based Narrowband UV-B Phototherapy for Patients With Psoriasis: The LITE Randomized Clinical Trial. JAMA Dermatol 2024:2823901. [PMID: 39319513 PMCID: PMC11425190 DOI: 10.1001/jamadermatol.2024.3897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 08/02/2024] [Indexed: 09/26/2024]
Abstract
Importance Office-based phototherapy is cost-effective for psoriasis but difficult to access. Home-based phototherapy is patient preferred but has limited clinical data, particularly in patients with darker skin. Objective To compare the effectiveness of home- vs office-based narrowband UV-B phototherapy for psoriasis. Design, Setting, and Participants The Light Treatment Effectiveness study was an investigator-initiated, pragmatic, open-label, parallel-group, multicenter, noninferiority randomized clinical trial embedded in routine care at 42 academic and private clinical dermatology practices in the US. Enrollment occurred from March 1, 2019, to December 4, 2023, with follow-up through June 2024. Participants were 12 years and older with plaque or guttate psoriasis who were candidates for home- and office-based phototherapy. Interventions Participants were randomized to receive a home narrowband UV-B machine with guided mode dosimetry or routine care with office-based narrowband UV-B for 12 weeks, followed by an additional 12-week observation period. Main Outcomes and Measures The coprimary effectiveness outcomes were Physician Global Assessment (PGA) dichotomized as clear/almost clear skin (score of ≤1) at the end of the intervention period and Dermatology Life Quality Index (DLQI) score of 5 or lower (no to small effect on quality of life) at week 12. Results Of 783 patients enrolled (mean [SD] age, 48.0 [15.5] years; 376 [48.0%] female), 393 received home-based phototherapy and 390 received office-based phototherapy, with 350 (44.7%) having skin phototype (SPT) I/II, 350 (44.7%) having SPT III/IV, and 83 (10.6%) having SPT V/VI. A total of 93 patients (11.9%) were receiving systemic treatment. At baseline, mean (SD) PGA was 2.7 (0.8) and DLQI was 12.2 (7.2). At week 12, 129 patients (32.8%) receiving home-based phototherapy and 100 patients (25.6%) receiving office-based phototherapy achieved clear/almost clear skin, and 206 (52.4%) and 131 (33.6%) achieved DLQI of 5 or lower, respectively. Home-based phototherapy was noninferior to office-based phototherapy for PGA and DLQI in the overall population and across all SPTs. Home-based phototherapy, compared to office-based phototherapy, was associated with better treatment adherence (202 patients [51.4%] vs 62 patients [15.9%]; P < .001), lower burden of indirect costs to patients, and more episodes of persistent erythema (466 of 7957 treatments [5.9%] vs 46 of 3934 treatments [1.2%]; P < .001). Both treatments were well tolerated with no discontinuations due to adverse events. Conclusions and Relevance In this randomized clinical trial, home-based phototherapy was as effective as office-based phototherapy for plaque or guttate psoriasis in everyday clinical practice and had less burden to patients. Trial Registration ClinicalTrials.gov Identifier: NCT03726489.
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Affiliation(s)
- Joel M. Gelfand
- Department of Dermatology, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - April W. Armstrong
- Division of Dermatology, Department of Medicine, University of California, Los Angeles
| | - Henry W. Lim
- Department of Dermatology, Henry Ford Health, Detroit, Michigan
| | - Steven R. Feldman
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | - Robert E. Kalb
- Department of Dermatology, SUNY at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Jeannette Jakus
- Deparment of Dermatology, SUNY Downstate Health Sciences University, Brooklyn, New York
| | | | - R. Hal Flowers
- Department of Dermatology, University of Virginia Health System, Charlottesville
| | - Tina Bhutani
- Department of Dermatology, University of California, San Francisco
| | - John R. Durkin
- Department of Dermatology, University of New Mexico, Albuquerque
| | - Jerry Bagel
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Scott Fretzin
- Dawes Fretzin Dermatology Group, Indianapolis, Indiana
| | - Michael P. Sheehan
- Department of Dermatology, Indiana University School of Medicine, Indianapolis
| | | | - Margo Reeder
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Jessica Kaffenberger
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus
| | | | - Junko Takeshita
- Department of Dermatology, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alisha M. Bridges
- Patient advocate and LITE study stakeholder committee member, Atlanta, Georgia
| | - Eric Fielding
- Patient advocate and LITE study stakeholder committee member, Melbourne, Florida
| | | | | | | | - Guy S. Eakin
- National Psoriasis Foundation, Alexandria, Virginia
| | - Suzette Báez
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Brooke E. Bishop
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | | | | | - William B. Song
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Kristin A. Linn
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Daniel B. Shin
- Department of Dermatology, University of Pennsylvania, Philadelphia
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Balak D, Perez-Chada LM, Guo LN, Mita C, Armstrong AW, Bell SJ, Gondo GC, Liao W, Merola JF. Definitions of Remission in Psoriasis: A Systematic Literature Review from the National Psoriasis Foundation. J Eur Acad Dermatol Venereol 2022; 36:2291-2300. [PMID: 35924437 DOI: 10.1111/jdv.18477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/12/2022] [Indexed: 11/28/2022]
Abstract
Psoriasis studies increasingly employ outcomes that indicate complete disease resolution, yet remission and cure are poorly defined for psoriasis. We conducted a systematic literature review to identify definitions of psoriasis remission and cure reported in the literature. Medline, EMBASE, and The Cochrane Central Register of Controlled Trials databases were searched on July 22, 2020 for full-text studies providing definitions for psoriasis remission/cure. Definitions were analyzed descriptively for endpoint, time-frame, on/off treatment, patient-reported outcomes, and disease domains. We identified 106 studies that provided 41 unique remission definitions. Most definitions included endpoints based on Psoriasis Area and Severity Index (PASI), such as PASI75 (n=16 studies), PASI90 (n=10), PASI100 (n=10), and PASI of 0 (n=3), and descriptive endpoints related to 'skin clearance' (n=18). Few definitions specified time-frame, on/off treatment or other psoriasis-related disease domains. One small consensus-initiative defined drug-free remission for plaque psoriasis by BSA of 0 without any therapy for at least 12 months. While there is no cure for psoriasis, seven studies defined psoriasis cure using similar endpoints to those used to define remission. We identified a variety of definitions of psoriasis remission. These results will inform the development of consensus-based definitions for psoriasis remission to support efforts to improve research and clinical outcomes.
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Affiliation(s)
- Dmw Balak
- Department of Dermatology, LangeLand Hospital, Zoetermeer, the Netherlands.,Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - L M Perez-Chada
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - L N Guo
- Harvard Medical School, Boston, MA, USA
| | - C Mita
- Countway Library of Medicine, Harvard University, Boston, Massachusetts, USA
| | - A W Armstrong
- Department of Dermatology, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - S J Bell
- National Psoriasis Foundation, Portland, OR, USA
| | - G C Gondo
- National Psoriasis Foundation, Portland, OR, USA
| | - W Liao
- Department of Dermatology, University of California, San Francisco, CA, USA
| | - J F Merola
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Addison R, Weatherhead SC, Pawitri A, Smith GR, Rider A, Grantham HJ, Cockell SJ, Reynolds NJ. Therapeutic wavelengths of ultraviolet B radiation activate apoptotic, circadian rhythm, redox signalling and key canonical pathways in psoriatic epidermis. Redox Biol 2021; 41:101924. [PMID: 33812333 PMCID: PMC8050411 DOI: 10.1016/j.redox.2021.101924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/22/2021] [Accepted: 02/26/2021] [Indexed: 01/09/2023] Open
Abstract
Ultraviolet B radiation (UVB) exerts pleiotropic effects on human skin. DNA damage response and repair pathways are activated by UVB; if damage cannot be repaired, apoptosis ensues. Although cumulative UVB exposure predisposes to skin cancer, UVB phototherapy is widely used as an effective treatment for psoriasis. Previous studies defined the therapeutic action spectrum of UVB and showed that psoriasis is resistant to apoptosis. This study aimed to investigate early molecular responses within psoriasis plaques following irradiation with single equi-erythemogenic doses of clinically-effective (311 nm, narrow-band) compared to clinically-ineffective (290 nm) UVB. Forty-eight micro-dissected epidermal samples from 20 psoriatic patients were analyzed using microarrays. Our bioinformatic analysis compared gene expression between 311 nm irradiated, 290 nm irradiated and control psoriasis epidermis to specifically identify 311 nm UVB differentially expressed genes (DEGs) and their upstream regulatory pathways. Key DEGs and pathways were validated by immunohistochemical analysis. There was a dynamic induction and repression of 311 nm UVB DEGs between 6 h and 18 h, only a limited number of DEGs maintained their designated expression status between time-points. Key disease and function pathways included apoptosis, cell death, cell migration and leucocyte chemotaxis. DNA damage response pathways, NRF2-mediated oxidative stress response and P53 signalling were key nodes, interconnecting apoptosis and cell cycle arrest. Interferon signalling, dendritic cell maturation, granulocyte adhesion and atherosclerotic pathways were also differentially regulated. Consistent with these findings, top transcriptional regulators of 311 nm UVB DEGs related to: a) apoptosis, DNA damage response and cell cycle control; b) innate/acquired immune regulation and inflammation; c) hypoxia/redox response and angiogenesis; d) circadian rhythmicity; f) EGR/AP1 signalling and keratinocyte differentiation; and g) mitochondrial biogenesis. This research provides important insights into the molecular targets of 311 nm UVB, underscoring key roles for apoptosis and cell death. These and the other key pathways delineated may be central to the therapeutic effects of 311 nm in psoriasis.
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Affiliation(s)
- Rachel Addison
- Institute of Translational and Clinical Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK
| | - Sophie C Weatherhead
- Institute of Translational and Clinical Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK; Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anandika Pawitri
- Institute of Translational and Clinical Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK
| | - Graham R Smith
- Bioinformatics Support Unit, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK
| | - Ashley Rider
- Institute of Translational and Clinical Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK
| | - Henry J Grantham
- Institute of Translational and Clinical Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK; Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Simon J Cockell
- Bioinformatics Support Unit, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK
| | - Nick J Reynolds
- Institute of Translational and Clinical Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle Upon Tyne, UK; Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
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Yanovsky RL, Huang KP, Buzney EA. Optimizing Narrowband UVB Phototherapy Regimens for Psoriasis. Dermatol Clin 2020; 38:1-10. [DOI: 10.1016/j.det.2019.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Shimizu T, Kamata M, Fukaya S, Hayashi K, Fukuyasu A, Tanaka T, Ishikawa T, Ohnishi T, Tada Y. Anti-IL-17A and IL-23p19 antibodies but not anti-TNFα antibody induce expansion of regulatory T cells and restoration of their suppressive function in imiquimod-induced psoriasiform dermatitis. J Dermatol Sci 2019; 95:90-98. [PMID: 31362906 DOI: 10.1016/j.jdermsci.2019.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 07/01/2019] [Accepted: 07/18/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Psoriasis is a chronic inflammatory skin disease. Anti-TNFα, IL-17A and IL-23p19 antibodies are effective for psoriasis. However, the contribution of regulatory T cells (Treg) in their effectiveness remains to be elucidated. OBJECTIVE We investigated the effects of TNFα, IL-17A and IL-23p19 inhibition on Tregs in imiquimod-induced psoriasiform dermatitis. METHODS Psoriasiform dermatitis was induced by imiquimod application on murine shaved back skin for six days. Mice were treated with anti-TNFα, IL-17A or IL-23p19 monoclonal antibodies every other day from one day before imiquimod application. RESULTS Administration of anti-TNFα, IL-17A or IL-23p19 antibodies improved the clinical score and downregulated Th17-related cytokines and chemokines, while IL-23p19 antibodies upregulated IL-10 mRNA expression. Anti-IL-17A or IL-23p19 antibody-treated imiquimod-applied mice showed a significant increase in the number of Foxp3+ IL-10+ Tregs. Recipient mice adoptively transferred with Tregs derived from donor mice treated with antibodies demonstrated clinical and pathological improvement in imiquimod-induced psoriasiform dermatitis. Anti-IL-17A or IL-23p19 antibody-induced Tregs significantly increased the number of Foxp3+ cells and IL-10 expression in imiquimod-induced psoriasiform dermatitis in recipient mice but anti-TNFα antibody-induced Tregs did not. CONCLUSION Anti-IL-17A or IL-23p19 antibody inhibits the IL-17/IL-23 signaling pathway, and induces expansion of Tregs and their suppressive capacity in imiquimod-induced psoriasiform dermatitis.
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Affiliation(s)
- Teruo Shimizu
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan
| | - Masahiro Kamata
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan.
| | - Saki Fukaya
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kotaro Hayashi
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan
| | - Atsuko Fukuyasu
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan
| | - Takamitsu Tanaka
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan
| | - Takeko Ishikawa
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan
| | - Takamitsu Ohnishi
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan
| | - Yayoi Tada
- Department of Dermatology, Teikyo University School of Medicine, Tokyo, Japan.
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Ryu HH, Choe YS, Jo S, Youn JI, Jo SJ. Remission period in psoriasis after multiple cycles of narrowband ultraviolet B phototherapy. J Dermatol 2014; 41:622-7. [PMID: 24942986 DOI: 10.1111/1346-8138.12541] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 05/18/2014] [Indexed: 11/30/2022]
Abstract
The aim of this study was to investigate the duration of remission periods in psoriasis after narrowband ultraviolet B (NB-UVB) phototherapy, especially during multiple cycles of treatment. We analyzed 63 patients (101 cases) demonstrating marked improvement after NB-UVB phototherapy. The remission period was defined as the duration of time from the end of phototherapy until treatment using either phototherapy or systemic treatments was required again. It was found that an age of 60 years or older, history of systemic therapy within 6 months and three or more phototherapy cycles were significantly associated with shorter remission periods. Furthermore, multivariate analysis confirmed that three or more phototherapy cycles (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.73-9.33; P = 0.001) and a history of systemic therapy (OR, 2.2; 95% CI, 1.27-3.95; P = 0.005) were independently associated with the shorter remission period. In conclusion, when planning NB-UVB phototherapy for psoriatic patients who have undergone multiple phototherapy cycles, clinicians should consider the possibility of shorter remission periods.
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Affiliation(s)
- Hyeong Ho Ryu
- Department of Dermatology, Seoul National University Hospital, Seoul, Korea
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