To paraphrase Mark Twain, rumors of phototherapy's demise have been greatly exaggerated, according to an expert.

"I thought the availability of biologics would impact phototherapy, and it did. It increased the amount of people coming in for phototherapy because the biologics have increased awareness among psoriasis patients" of phototherapy's utility, says Jerry Bagel, M.D., director of the Psoriasis Treatment Center of Central New Jersey and clinical assistant professor of dermatology at Columbia University.

Some patients do well with narrowband UVB and are able to avoid biologics, he adds.

"Others who go on biologics and don't clear completely do well by having the adjunctive effects of phototherapy. Therefore, our phototherapy practice is bigger than ever," Dr. Bagel says. He estimates that his practice treats more than 150 psoriasis patients weekly with this modality. Most have moderate to severe disease that doesn't respond to topical therapies.

Dr. Bagel's experience with combination therapy, moreover, dates to 1998, when he was involved with clinical trials of Amevive (alefacept, Astellas). During those trials, he says, "We found that some people with residual psoriasis, after stopping alefacept treatment, did pretty well when we gave them phototherapy. And they didn't require as much light as they did without Amevive." (Paper presented at: 80th Annual Conference of the Canadian Dermatology Association; June 28-July 3, 2005; Québec City.)

In a later study of Enbrel (etanercept, Immunex), he adds, "We found exceptionally good results. In fact, almost all of our patients who had 12 weeks of Enbrel and 12 weeks of narrowband UVB cleared (publication pending)."

MORE AGGRESSIVE

Since then, Dr. Bagel says, "I've been going more aggressively with narrowband UVB."

He bases initial doses on patients' skin types, he explains. But he says that increasing subsequent doses by 10 percent of the prior dose, and continuing to do so without any firm upper limit per session, seems to clear patients in 20 percent fewer visits.

"I'm also using Soriatane (acitretin, Roche Holding AG) more often, starting at 25 mg daily for 12 weeks, then 10 mg daily," Dr. Bagel says. At these doses, he says he's finding that people tolerate the drug much more easily.

"They get good benefits without any adverse events. So I can use Soriatane with light and biologics at the same time," he says.

Dr. Bagel adds that although he's still using PUVA, he rarely uses it with biologics.

"Because of the photo adduct of psoralen," he says, "I don't want to use it with biologics if I can help it. But there are some instances where I have used it — for instance, in combination with Raptiva (efalizumab, Genentech) or Remicade (infliximab, Centocor)."

In such cases, he says the combination has been very efficacious for short-term treatment. Likewise, he says that for patients with hand and foot psoriasis, "Even if I start them on efalizumab, I still can use some topical PUVA to help them along."

WILL REMAIN VIABLE

In keeping with Dr. Bagel's clinical experience, he says that phototherapy will remain viable at least until biologic drugs can further increase their efficacy and minimize side effects.

"Although it might be inconvenient for some people to come in thrice weekly for seven weeks for phototherapy, a majority of patients with moderate-to-severe psoriasis do well with narrowband UVB, and in many cases have significant remissions," he says. Since narrowband UVB seems to be "almost completely safe," Dr. Bagel adds, "There's no reason at this point to consider it anything less than an important form of therapy," a role that will persist for the foreseeable future, perhaps in combination with biologics.

"All the biologics carry certain risks regarding infection or possible malignancy. Even though they are wonderful drugs and especially helpful when phototherapy does not work, phototherapy remains extremely valuable because of its safety and efficacy," he says.

Likewise, Dr. Bagel says that PUVA's future looks relatively bright because the purported risks of skin cancer associated with this modality have perhaps been exaggerated.

"There's been one article that showed an increased risk of melanoma (Stern RS et al. N Engl J Med. 1997 Apr 10;336(15):1041-1045). However, that study used patients who participated in the original PUVA trials 25 years ago and possibly had been exposed to radiation from Grenz ray previously," he says.

Conversely, he says, "There have been 20 articles that have shown no increase in melanoma or in skin cancers in non-Caucasians" as a result of PUVA therapy.

Disclosure: Dr. Bagel has served as a speaker for Genentech, Amgen and Abbott.