Use of Phototherapy in Children

Phototherapy for the treatment of atopic dermatitis in Singaporean children and adolescents

BACKGROUND/PURPOSE

Phototherapy has emerged as a safe yet effective form of treatment of atopic dermatitis (AD). Few studies have been done to evaluate the efficacy of phototherapy in Asian children. The aim of this study was to review the phototherapy experience in a cohort of Asian pediatric patients with AD at a tertiary dermatologic center in Singapore.

METHODS

A retrospective study of patients 18 years and below with AD who had undergone phototherapy at KK Women's and Children's Hospital, Singapore, over a 4-year period was performed.

RESULTS

Sixty-two patients were identified, between ages 4 and 16 years (mean age 11 years) at the time of commencement of phototherapy. Thirty-five (60%) patients were males and 23 (40%) were females. Most patients had moderate to severe disease, with 60.3% of the patients with an initial body surface area (BSA) involvement of 31%-60% and 13.8% of the patients with an initial BSA involvement of 61%-90%. For patients who had undergone narrowband ultraviolet B (NBUVB) and combined ultraviolet A (UVA) and NBUVB phototherapy, the mean reduction of the Eczema Area and Severity Index (EASI) scores were 11.4 and 7.9, respectively. Common side effects experienced include xerosis, pruritus, erythema, and pain. Other reasons for cessation of therapy in the NBUVB group included time commitment difficulty (9.3%), hyperactivity (2.3%), and claustrophobia (2.3%). Two patients that had photochemotherapy (psoralen + UVA) [PUVA] suffered from post-UVA burns requiring cessation of treatment. More than half of the patients (56.9%) treated with phototherapy experienced treatment success with improvement in Investigator Global Assessment and EASI scores. 86.2% of the patients had good compliance to the treatment regime, 12% had poor-compliance, and 3.4% were lost to follow-up.

CONCLUSION

Phototherapy is a useful treatment adjunct for moderate to severe AD in Asian children.

Current practices for pediatric phototherapy: Findings from a cross-sectional study

Phototherapy is broadly utilized for treatment of inflammatory skin conditions affecting pediatric patients. However, there are no specific guidelines or recommendations for implementing phototherapy in pediatric populations leading to variability in treatment procedures. Here, we present findings from a cross-sectional, survey-based study investigating the implementation of phototherapy in pediatric patients across the United States. A total of 39 sites from 19 different states identified via the National Psoriasis Foundation (NPF) Health Care Provider Directory responded. Common practices included a signed informed consent prior to performing phototherapy (86.4%, n = 32), no minimum age requirement for pediatric patients (91.8%, n = 34), the use of Fitzpatrick skin type to determine dosing protocol (100%, n = 37), and allowing parents to accompany their children into the lightbox (65%, n = 20). Our results provide insights into current common practices and themes for further study.

Phototherapy as a Treatment for Dermatological Diseases, Cancer, Aesthetic Dermatologic Conditions and Allergenic Rhinitis in Adult and Paediatric Medicine

The development of light-emitting diodes (LEDs) has led to an increase in the use of lighting regimes within medicine particularly as a treatment for dermatological conditions. New devices have demonstrated significant results for the treatment of medical conditions, including mild-to-moderate acne vulgaris, wound healing, psoriasis, squamous cell carcinoma in situ (Bowen's disease), basal cell carcinoma, actinic keratosis, and cosmetic applications. The three wavelengths of light that have demonstrated several therapeutic applications are blue (415 nm), red (633 nm), and near-infrared (830 nm). This review shows their potential for treating dermatological conditions. Phototherapy has also been shown to be an effective treatment for allergenic rhinitis in children and adults. In a double-anonymized randomized study it was found that there was 70% improvement of clinical symptoms of allergic rhinitis after intranasal illumination by low-energy narrow-band phototherapy at a wavelength of 660 nm three times a day for 14 consecutive days. Improvement of oedema in many patients with an age range of 7-17 were also observed. These light treatments can now be self-administered by sufferers using devices such as the Allergy Reliever phototherapy device. The device emits visible light (mUV/VIS) and infra-red light (660 nm and 940 nm) wavelengths directly on to the skin in the nasal cavity for a 3 min period. Several phototherapy devices emitting a range of wavelengths have recently become available for use and which give good outcomes for some dermatological conditions.

Treatment options for moderate to severe atopic dermatitis

Background: The treatment of chronic refractory moderate-to-severe atopic dermatitis (AD) has traditionally relied on broad-spectrum systemic anti-inflammatory agents. With the introduction of biologics and Janus kinase inhibitors (Jakinib), the step management of moderate-to-severe AD is rapidly changing; however, guidelines have yet to provide formal recommendations for how to best incorporate these agents into the treatment plan. Objective: To summarize the updated evidence-based medical treatment for AD, including a proposed position for biologics and Jakinibs in the treatment algorithm. Methods: A literature search of several medical literature data bases for guidelines, position papers, systematic reviews, and clinical trials from 2012 to 2022 on the treatment of moderate-to-severe AD was conducted to prepare this narrative review. Results: Emollients and topical corticosteroids are the mainstay for treating acute flares and for maintaining chronic control. Second-line topical agents include calcineurin inhibitors, e.g., tacrolimus and pimecrolimus; crisaborole; and ruxolitinib. For acute flares, cyclosporine is preferred over systemic corticosteroids. For chronic treatment, phototherapy should be considered before systemic anti-inflammatory agents. Of the traditional anti-inflammatory agents, cyclosporine is the first-line choice, with methotrexate and azathioprine equal secondary choices. Although abrocitinib may have better efficacy then dupilumab based on indirect comparisons, abrocitinib requires closer monitoring for adverse events. Based on package labeling, Jakinibs, e.g., abrocitinib and upadacitinib, should be used only after failure with other systemic agents, including biologics (e.g., dupilumab and tralokinumab). Biologics and Jakinibs should be considered before the traditional systemic anti-inflammatory agents. Conclusion: Clinicians should consider a modified step management for AD as they await the development of national and international guideline recommendations for how best to position the biologics and Jakinibs into the AD treatment algorithm.

Phototherapy in dermatological maladies (Review)

Since the introduction of modern phototherapy in 1903 by Nobel Prize-winner Niels Ryberg Finsen, the usage of this therapy in the medical field has grown, techniques have been refined and developed, and it has gained widespread acceptance. Psoriasis vulgaris, parapsoriasis, lichen planus, atopic dermatitis, neonatal jaundice, urticaria, morphea, vitiligo, granuloma annulare and cutaneous T cell lymphoma are only a few dermatological indications that come along with satisfactory results. Most often, it is a 2nd or 3rd line therapy being an alternative in more severe or refractory diseases. Despite the side effects that may occur after phototherapy, which are often minor, the benefits can be significant. Unfortunately, the absolute contraindications limit the use of this type of treatment and implicitly the management of these patients. The current review aimed to combine the recommendations of phototherapy in dermatology, the types of phototherapy that can be suitable for certain dermatological diseases and to emphasize its importance in certain conditions that are associated with significant remission rates.

An Update on Narrowband Ultraviolet B Therapy for the Treatment of Skin Diseases

The objective of this review is to provide an update on narrowband ultraviolet B (NB-UVB) as a treatment for various skin conditions. NB-UVB works by suppressing the cutaneous cell-mediated immune response and has been shown to be an efficacious and clinically tolerable treatment for a range of inflammatory dermatoses. A literature search was conducted by advanced searches of PubMed for NB-UVB treatment of dermatologic skin diseases with a focus on reports from 2010 to 2021, including both office-based and home-based phototherapy (HBPT). Data were prioritized based on studies with a high level of evidence using the Oxford Evidence-Based Medicine guidance.

We found that NB-UVB continues to serve as an effective form of therapy for several cutaneous conditions, including vitiligo, psoriasis, atopic dermatitis, mycosis fungoides, and other inflammatory dermatoses. The recent introduction of Janus kinase inhibitors in combination with NB-UVB suggests future promise in the treatment of vitiligo. Despite its rise in popularity, a decline was seen in office-based NB-UVB treatment during the coronavirus disease 2019 pandemic. Options are available to deliver NB-UVB at home with comparable efficacy to office-based treatments. In conclusion, for a select group of patients and conditions, NB-UVB continues to serve as an effective treatment modality with minimal side effects, with HBPT serving as an option to improve patient compliance.

Mediator-Related Symptoms and Anaphylaxis in Children with Mastocytosis

Mastocytosis is characterized by the pathological accumulation of mast cells (MC) in various organs. In these patients, MC may degranulate and thereby contribute to clinical symptoms, especially when a concomitant allergy is present. However, MC activation can not only be induced by high-affinity receptors for IgE, but also by anaphylatoxins, neuropeptides, IgG immune complexes, complement-components, drugs, products of bacteria or parasites, as well as physical factors such as heat, cold, vibration, stress, sun, or physical effort. Symptoms due to mediators released by activated MC may develop in adults suffering from systemic mastocytosis, but also evolve in children who usually have cutaneous mastocytosis (CM). Clinically, CM is otherwise characterized by typical brown, maculopapular skin lesions or mastocytoma associated with a positive Darier's sign. Pruritus and flushing are common and blistering may also be recorded, especially in diffuse CM (DCM). Pediatric patients with mastocytosis may also have gastrointestinal, respiratory, and neurologic complaints. Although anaphylaxis is not a typical finding, pediatric patients with massive skin involvement and high tryptase levels have a relatively high risk to develop anaphylaxis. This paper reviews MC mediator-related symptoms and anaphylaxis in children with mastocytosis, with special emphasis on risk factors, triggers, and management.

Molecular Background, Clinical Features and Management of Pediatric Mastocytosis: Status 2021

Pediatric mastocytosis is a heterogeneous disease characterized by accumulation of mast cells in the skin and less frequently in other organs. Somatic or germline mutations in the KIT proto-oncogene are detected in most patients. Cutaneous mastocytosis is the most common form of the disease in children. In the majority of cases, skin lesions regress spontaneously around puberty. However, in few patients, mastocytosis is not a self-limiting disease, but persists into adulthood and can show signs of systemic involvement, especially when skin lesions are small-sized and monomorphic. Children with mastocytosis often suffer from mast cell mediator-related symptoms. Severe hypersensitivity reactions can also occur, mostly in patients with extensive skin lesions and blistering. In a substantial number of these cases, the triggering factor of anaphylaxis remains unidentified. Management of pediatric mastocytosis is mainly based on strict avoidance of triggers, treatment with H1 and H2 histamine receptor blockers, and equipment of patients and their families with epinephrine auto-injectors for use in severe anaphylactic reactions. Advanced systemic mastocytosis occurs occasionally. All children with mastocytosis require follow-up examinations. A bone marrow investigation is performed when advanced systemic mastocytosis is suspected and has an impact on therapy or when cutaneous disease persists into adulthood.

Off-Label Treatments for Pediatric Psoriasis: Lessons for the Clinic

Psoriasis is a chronic inflammatory skin disease that affects up to 1.2% of children and adolescents. The treatment options for childhood psoriasis are often based on the same principles as in adults. However, most data on safety and efficacy derive from adult studies, and only a few of the frequently used treatments have achieved approval for use in children. The aim of this study was to review the current literature on off-label treatments for psoriasis in children and adolescents. We searched PubMed and identified 50 studies on off-label treatments. Of these, 23 studies were clinical trials (four randomized). There are only a small number of available studies on off-label treatments for children and adolescents with psoriasis, and many of these are retrospective reviews with few participants. Despite the current lack of studies, we still recommend the use of unapproved treatments since we have clinical experience with treatments such as topical corticosteroids, vitamin D analogs, and methotrexate that have shown promising effects. Regular clinical trials are needed to investigate the safety and efficacy of unapproved treatments. Due to The Pediatric Investigation Plans issued by The European Union, new drugs developed by pharmaceutical companies are required to undergo clinical trials in a pediatric population to get their application for marketing authorization processed. This will hopefully lead to much more data on the efficacy and safety of the new treatments, including treatments for children and adolescents with psoriasis.

Current Perspectives on the Management of Infantile Atopic Dermatitis

Atopic dermatitis (AD) is a common disease of childhood, and infantile AD may manifest from birth to 2 years. Guidelines for the management of infantile AD are lacking, and our aim is to provide a comprehensive review of best practices and possible interventions. We will focus on topical therapy, since the use of systemic immunomodulating agents in infantile AD is rarely advised. Topical agents include emollients, topical corticosteroids (TCS), topical calcineurin inhibitors (TCIs), and phosphodiesterase 4 (PDE-4) inhibitors. We will also provide a brief overview of promising emerging therapies currently under investigation in the pediatric population.

A retrospective review of phototherapy in children, at a tertiary paediatric dermatology unit

BACKGROUND/PURPOSE

To examine the efficacy, tolerability and safety of phototherapy in children, in whom there is currently a paucity of data.

MATERIALS AND METHODS

Retrospective review of children under 18 years who received narrowband UVB (NB-UVB), broadband UVB (BB-UVB) phototherapy or psoralen with UVA (PUVA) photochemotherapy between 2003 and 2017 at a tertiary Paediatric dermatology centre in Southampton, UK.

RESULTS

100 children aged 6-17 years were included. The majority of children had psoriasis (74), atopic dermatitis (10) or vitiligo (8), with others having rarer dermatoses. Grade 2 erythema or above occurred in 46% of all included children and 42% (36/86) of those receiving NB-UVB; however, grade 3 and 4 reactions were infrequent and only 3 children stopped treatment due to burning. NB-UVB was particularly effective in those with psoriasis; 55/65 (85%) significantly improved, and 72% had not relapsed after 2 years. However, its effectiveness in atopic dermatitis was less convincing; in a small group of children, 6/10 (60%) significantly improved, but 66% relapsed within 3 months.

CONCLUSIONS

Our analysis demonstrates that NB-UVB is effective in children with psoriasis and vitiligo, with potential to achieve extended periods of remission in psoriasis. Its usefulness in atopic dermatitis is less clear. The long-term safety of NB-UVB in children is still unknown, but it appears to be a well-tolerated treatment and should be considered in children for a variety of inflammatory dermatoses before progressing to immunosuppressive therapies.

NB-UVB Induces Melanocytic Differentiation of Human Hair Follicle Neural Crest Stem Cells

Background

Phototherapy is an important method to treat vitiligo. However, it is unclear how phototherapy affects melanocyte precursors and skin neural crest stem cells.

Objective

To investigate the underlying mechanisms of narrow-band ultraviolet B (NB-UVB) induced melanocyte lineage differentiated from human scalp-derived neural crest stem cells (HS-NCSCs).

Methods

HS-NCSCs were expanded from scalp hair follicles. The c-Kit^-/CD57^- HS-NCSCs were isolated by cell sorting. Different doses of NB-UVB were used to irradiate these HS-NCSCs. Cell ultrastructure was examined by transmission electron microscope. Melanocyte marker expression was analyzed by Quantitative RT-PCR and Western blot. Cell proliferation and migration were also evaluated.

Results

The c-Kit^-/CD57^- HS-NCSCs expressed embryonic NCSC biomarkers. NB-UVB at a dose of 100 mJ of NB-UVB had little effect on the cell proliferation of differentiated melanocytes from c-Kit^-/CD57^- HS-NCSCs, while 700 mJ inhibited cell proliferation significantly. The dendritic processes of differentiated melanocytes increased after radiation. The tyrosinase and Melanocortin 1 receptor (Mc1R) expression of differentiated melanocytes increased after NB-UVB exposure. The effect of NB-UVB on tyrosinase expression was modulated by signaling inhibitors H89 and PD98059 as well as Mc1R level in the cells. The migration ability of differentiated melanocytes was enhanced under 100 mJ exposure.

Conclusion

These data demonstrate that NB-UVB facilitates melanocytic differentiation of the HS-NCSCs and enhances migration of these cells. Mc1R and cAMP pathway play a critical role in NB-UVB induced melanocytic differentiation.

Phototherapy in the Pediatric Population

Phototherapy has been used successfully to treat a wide range of pediatric skin conditions. It is a viable option in children with severe dermatologic disease or who have failed first-line treatments, and several studies have demonstrated its efficacy and safety in the pediatric population. Despite the growing body of evidence on the use of phototherapy in children, large controlled trials and long-term studies are lacking. Moreover, special considerations must be taken when using phototherapy in children. This review highlights the recent evidence supporting the efficacy and safety of phototherapy in children, with focus on the common light-sensitive pediatric skin conditions.

Atopic dermatitis yardstick: Practical recommendations for an evolving therapeutic landscape

The implementation of treatment guidelines for atopic dermatitis is challenging, in part because of different guidance documents being used by different groups of specialists and in part because the language of guidelines often reflects the evidence base rather than the practical "how to." The Atopic Dermatitis Yardstick is part of a series developed in response to the need to proactively address the loss of disease control for atopic illnesses at all levels of severity. It presents a comprehensive update on how to conduct a sustained step-up in therapy for the patient with inadequately controlled or poorly controlled atopic dermatitis. Patient profiles, based on current guidelines and the authors' combined clinical experience, provide a practical and clinically meaningful guide to aid physicians in helping their patients achieve the goal of clear to almost clear. The intent is not to replace guidelines but to complement their recommendations incorporating the latest research and therapies.

Pediatric psoriasis: Evolving perspectives

BACKGROUND/OBJECTIVES

Childhood-onset psoriasis is a common skin disorder that has recently received increasing attention, particularly because of its significant medical, social, financial, and psychological burdens and its associated comorbidities. With limited data available and lack of standardized management guidelines for pediatric psoriasis, an expert panel desired to provide an updated critical overview and practical guidance for management of the affected population.

METHODS

A panel of pediatric dermatologists with extensive experience in pediatric psoriasis defined and prioritized a core set of topics, performed an English-language literature review, prepared critical evaluations and presentations of topic areas, and carried out a consensus meeting and follow-up consensus manuscript.

RESULTS

The summation of evolving perspectives in pediatric psoriasis includes epidemiology and natural history of the disease, precipitating factors and comorbidities, quality of life and burden of disease, clinical features and disease presentation, differential diagnosis, pathogenesis and treatment, including topical, photo, and systemic therapies.

CONCLUSION

Pediatric psoriasis is an important immune-mediated inflammatory skin disease with potential for significant impact on affected individuals and their caregivers. Current state-of-the-art care is based primarily on experience and expert consensus, but pediatric data are accumulating and therapeutic options are rapidly evolving.