Phototherapy or Biologics: Which is Better for Psoriasis?

Psoriasis, a chronic inflammatory skin condition, affects millions of people worldwide. The pursuit of effective treatments has led to the development of various options, including biologics and phototherapy. While biologics often dominate the conversation, phototherapy remains a crucial yet sometimes underappreciated treatment. To shed light on phototherapy and its role in dermatological care, I had the pleasure of discussing this topic with Dr. Joel M Gelfand MD MSCE , the Director of the Center for Clinical Sciences in Dermatology and Psoriasis and Phototherapy Treatment Center at the University of Pennsylvania's Perelman School of Medicine. Dr. Gelfand’s insights provide a deeper understanding of how phototherapy works, its benefits, and its place in modern dermatology.

The Mechanism of Phototherapy

Phototherapy, also known as light therapy, involves the use of ultraviolet (UV) light to treat various skin conditions, including psoriasis. The treatment utilizes UVB light, which penetrates the skin and modulates the immune response. Dr. Gelfand explained, "Phototherapy modulates the immune response in the skin by targeting pathways also affected by biologics, such as cytokines like IL-17 and TNF, which are key drivers of psoriatic disease. Interestingly, phototherapy also lowers interleukin-6, impacting both skin and blood levels, suggesting potential cardiovascular benefits."

The primary action of UV phototherapy is to reduce the activity of antigen-presenting cells, which play a critical role in the immune response associated with psoriasis. By diminishing these cells, phototherapy can induce long-lasting remissions, helping patients manage the disease effectively. This mechanism highlights the potential of phototherapy as a natural and effective treatment for psoriasis.

Phototherapy vs. Biologics

Biologics, a class of drugs that target specific components of the immune system, have gained popularity due to their efficacy in treating moderate to severe psoriasis. However, phototherapy offers a different approach, one that Dr. Gelfand believes deserves more attention. "I advocate for shared decision-making, empowering patients with information to make choices that fit their values and situations," he said. Depending on the severity of the disease, underlying health issues, and personal preferences, phototherapy can be an excellent option, especially for patients seeking a more natural treatment.

One significant advantage of phototherapy is its cost-effectiveness. Biologics are expensive, with annual costs running into tens of thousands of dollars. In contrast, phototherapy, particularly home phototherapy, can be more affordable and accessible. Dr. Gelfand emphasized, "Home phototherapy has shown promise, providing similar or better outcomes with greater adherence and convenience, potentially reducing healthcare costs in the long run."

Cardiovascular Benefits and Holistic Care

A fascinating aspect of phototherapy is its potential cardiovascular benefits. Dr. Gelfand noted, "Phototherapy lowers interleukin-6, which impacts both skin and blood levels, suggesting potential cardiovascular benefits. However, while we cannot definitively say that treating psoriasis reduces cardiovascular events, controlling skin inflammation undoubtedly improves patients' quality of life."

Holistic care is crucial in managing psoriasis, given its association with various comorbidities, including cardiovascular disease. Dr. Gelfand advocates for a multi-pronged approach: "We must also address other cardiovascular risk factors, such as insulin resistance, diabetes, dyslipidemia, hypertension, and lifestyle habits like smoking. As dermatologists, it's crucial to provide holistic care, including cardiovascular screening and encouraging healthy lifestyle choices to mitigate heart disease risks."

The Impact on Mental Health

The routine visits required for phototherapy may also have positive effects on patients' mental health. Regular interaction with healthcare providers can enhance patients' overall outlook and quality of life. Dr. Gelfand shared, "The frequent contact with healthcare providers during phototherapy can significantly improve mental well-being. Regular interaction with empathetic staff can enhance patients' overall outlook and quality of life."

This aspect of phototherapy underscores the importance of patient-centered care. The supportive environment provided by regular visits can help patients feel more connected and less isolated, contributing to improved mental health outcomes.

The Role of Home Phototherapy

The COVID-19 pandemic has accelerated the adoption of home phototherapy, making it a viable option for many patients. Home phototherapy allows patients to receive treatment in the comfort of their homes, reducing the inconvenience and cost associated with frequent clinic visits. Dr. Gelfand discussed the impact of home phototherapy: "In our study, we found that home phototherapy provided similar or better outcomes compared to in-office treatment, with greater adherence and convenience."

Home phototherapy devices, such as the Davlin 7 Series, are designed to be user-friendly and safe. These devices can be prescribed by dermatologists, and they adjust the dosage based on the patient's skin type and treatment history. This advancement has made phototherapy more accessible, particularly for patients in rural areas or those with busy schedules.

Patient Adherence and Efficacy

Patient adherence is crucial for the success of any treatment, and phototherapy is no exception. Dr. Gelfand highlighted the importance of adherence: "Patients tend to adhere better to home phototherapy because it fits more easily into their daily routines. This higher adherence rate translates into better treatment outcomes."

The efficacy of phototherapy varies among patients, with remission durations ranging from six months to a year or more. Factors influencing remission include disease duration, environmental influences, and individual patient characteristics. Dr. Gelfand explained, "Remission duration varies widely, often lasting six months to a year. Factors include disease duration, environmental influences, and individual patient characteristics."

Skin Type Considerations

Phototherapy can be effective for patients with different skin types, though dosing adjustments are necessary. Dr. Gelfand shared insights from recent studies: "Phototherapy is effective across all skin types, though dosing must be adjusted appropriately. Recent studies show that patients with darker skin, when treated correctly, can achieve excellent outcomes."

Proper dosing and adherence are crucial for maximizing the benefits of phototherapy. Dermatologists must consider patients' skin types and adjust treatment protocols to ensure safety and efficacy.

Broader Applications of Phototherapy

While psoriasis is a primary indication for phototherapy, this treatment modality has broader applications in dermatology. Dr. Gelfand noted, "Besides psoriasis, phototherapy is effective for eczema, chronic itch, cutaneous T-cell lymphoma, and various inflammatory skin conditions. Its neuromodulatory effects are particularly beneficial for managing chronic itch, though the exact mechanisms remain under investigation."

The versatility of phototherapy makes it a valuable tool in dermatological care, offering benefits for a range of skin conditions. As research continues, the potential applications of phototherapy may expand further, providing new avenues for treatment.

Future Directions and Advancements

Looking ahead, Dr. Gelfand anticipates continued advancements in phototherapy, particularly in the integration of home devices and the use of technology to enhance patient care. "I anticipate increased use of home phototherapy, supported by technological advances and insurance coverage improvements. Providing more patient-centered care, especially in underserved areas, will enhance treatment accessibility and effectiveness," he said.

The potential role of artificial intelligence (AI) in phototherapy is also an exciting prospect. AI could help personalize treatment protocols, monitor patient adherence, and predict treatment outcomes, further enhancing the efficacy and convenience of phototherapy.

Take Aways

Phototherapy remains a cornerstone of psoriasis treatment, offering a natural, cost-effective, and patient-centered approach. Dr. Joel Gelfand's insights underscore the importance of this treatment modality and its potential benefits beyond skin clearance, including improved cardiovascular and mental health outcomes. As technology advances and patient-centered care becomes more prevalent, phototherapy will continue to play a vital role in dermatological care, providing effective solutions for patients with psoriasis and other skin conditions.

For those seeking a deeper understanding of phototherapy and its place in modern dermatology, this conversation with Dr. Gelfand offers valuable insights and highlights the importance of considering all available treatment options to provide the best care for patients.