REVIEW
A guide to prescribing home phototherapy for patients with psoriasis: The appropriate patient, the type of unit, the treatment regimen, and the potential obstacles Kathryn L. Anderson, BS,a and Steven R. Feldman, MD, PhDa,b,c Winston-Salem, North Carolina Background: Ultraviolet B phototherapy is underused because of costs and inconvenience. Home phototherapy may alleviate these issues, but training is spotty, and many physicians are not comfortable prescribing home phototherapy. Objective: The purpose of this review is to provide a practical guide for recognizing appropriate patients, prescribing, and dealing with potential obstacles for home phototherapy treatment. Methods: Current guidelines for treatment of psoriasis were used to describe an appropriate patient for home phototherapy. Current literature and resources from phototherapy providers were reviewed to determine appropriate type of light, unit, treatment regimen, and how to navigate the insurance claim process. Results: Treatment schedules vary based on skin type. Home phototherapy companies provide various units suited for individual situations. Assistance can be used from suppliers to facilitate the process of obtaining a home phototherapy unit and navigating obstacles. Limitations: Phototherapy treatment varies on an individual basis, so this review serves only as a guide. Conclusion: Home phototherapy is a suitable treatment for many patients for whom office-based phototherapy is not accessible. Home phototherapy companies simplify the process by providing assistance for prescribing home light units. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2015.02.003.) Key words: broadband ultraviolet B; home phototherapy; insurance; narrowband ultraviolet B; phototherapy; psoriasis; ultraviolet A.
U
ltraviolet (UV) B phototherapy is a first-line treatment for extensive psoriasis and is a second-line treatment for localized psoriasis not responding to topical medications.1-3 Phototherapy, however, is often underused because From the Center for Dermatology Research, Department of Dermatology,a Department of Pathology,b and Department of Public Health Sciences,c Wake Forest School of Medicine. The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories LP. Disclosure: Dr Feldman is a speaker for Janssen and Taro. He is a consultant and speaker for Galderma, Stiefel/GlaxoSmithKline, Abbott Labs, Leo Pharma Inc, and Novartis. He has received grants from Galderma, Janssen, Abbott Labs, Amgen, Stiefel/GlaxoSmithKline, Celgene, and Anacor. He is a consultant for Amgen, Baxter, Caremark, Gerson Lehrman Group, Guidepoint Global, Hanall Pharmaceutical Co Ltd, Kikaku, Lilly, Merck & Co Inc, Merz Pharmaceuticals, Mylan, Novartis Pharmaceuticals, Pfizer Inc, Qurient, Suncare Research, and Xenoport. He is on an
Abbreviations used: MED: NB: UV:
minimal erythema dose narrowband ultraviolet
advisory board for Pfizer Inc, Abbvie, and Celgene. He is the founder and holds stock in Causa Research and holds stock and is majority owner in Medical Quality Enhancement Corp. He receives Royalties from UpToDate and Xlibris. Ms Anderson has no conflicts of interest to declare. Accepted for publication February 1, 2015. Reprint requests: Kathryn L. Anderson, BS, Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071. E-mail: [email protected]. Published online March 5, 2015. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.02.003
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of prohibitive copayment costs or inconvenience to office or home-based phototherapy (Table I).1,8 the patient of office-based phototherapy treatments, Unlike many systemic treatments for moderate to particularly in the United States.4,5 Phototherapy may severe psoriasis, phototherapy is a relatively safe treatment option for immunosuppressed be the lowest cost option compared with biologics, patients, patients with ongoing infections, patients but not necessarily from the patients’ standpoint currently on medications that would pose a pharmabecause of multiple copays, driving time, driving cologic interaction with systemic medications, paexpenses, lost wages, cost of equipment, or a tients with comorbidities combination of these.5 limiting the medication opInconvenience and cost can CAPSULE SUMMARY tions, children, and women be minimized by prescribing who are pregnant or breasta home light unit.4 In addiHome phototherapy is an efficacious and feeding.1,2 tion, home phototherapy can reasonably safe treatment for psoriasis, be as effective as officeHome phototherapy is but training in prescribing it is poor. based phototherapy, while well suited for patients who Prescribing home phototherapy can be increasing patient satisfacare unable to attend outpastreamlined with the assistance of home tion with treatment.6 tient phototherapy because Resident training for using light unit providers. of distance from phototherphototherapy as treatment is apy site, cost of travel and Communication among patient, lacking.7 The purpose of this lost wages, or time conflicts.9 physician, phototherapy provider, and review is to provide a pracHome phototherapy can be insurance carrier will facilitate the tical guide for recognizing used for long-term mainteavailability of home phototherapy. the appropriate patient for nance in patients who have home light treatment, precleared using office-based scribing home light treatphototherapy (in which case the patient should ment, and dealing with potential obstacles, such as already have a good understanding of the proaffordability and insurance issues. cedures, side effects, and signs of adequate treatment) or de novo in patients who are just starting a METHODS phototherapy regimen.9 Home phototherapy is also The guidelines for treatment of psoriasis puban appropriate treatment for individuals with locallished by Journal of the American Academy of ized lesions who have failed topical treatments, Dermatology,1 the guide for treatment from The those would prefer to not use topical treatments, or National Psoriasis Foundation,2 and ‘‘A Clinician’s as an adjunctive treatment.10 There are a variety of 3 Paradigm in the Treatment of Psoriasis’’ were used spot-treatment home phototherapy devices deto describe an appropriate patient for home photosigned for localized lesions, scalp lesions, and palms therapy. The phototherapy companies to include in and soles.11-14 this review were determined based on those listed by Many patients may benefit from a trial of photothe National Psoriasis Foundation via their World therapy before moving on to other systemic treatWide Web site (http://www.psoriasis.org/aboutments that may be associated with more risks, higher psoriasis/treatments/phototherapy/uvb/home-equip costs, or both. To make phototherapy available to a ment). World Wide Web sites, catalogs, and larger number of patients, home phototherapy may personnel from phototherapy unit providers were be a favorable option. used to gather information regarding their products and how to navigate the insurance claim process. Prescribing the appropriate phototherapy Current literature was reviewed to recommend treatment treatment regimens for home phototherapy units, When prescribing home phototherapy, the preincluding type of light, type of unit, and treatment scription should indicate the type of UV light to be schedule. used and the type of light unit. Also, the treatment schedule needs to be determined and communicated clearly to the patient. RESULTS Type of UV light to prescribe. Broadband Recognizing the appropriate patient to receive UVB, narrowband (NB) UVB, and psoralen plus home phototherapy UVA can all be used to treat psoriasis. Randomized, Phototherapy is a first-line treatment for psoriasis, blinded trials have been done comparing the particularly if too extensive to be treated with 3 options as a form of in-office phototherapy. topicals alone (often defined by [10% body surface NB-UVB is more efficacious than broadband UVB area).1-3 There are very few contraindications for d
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Table I. Checklist for providers prescribing home light treatment 1. Determine if the patient is appropriate for phototherapy A. Strongly consider contraindications: d History of photosensitivity disorder, including xeroderma pigmentosum, lupus erythematosus, dermatomyositis, and porphyria disorders d Use of photosensitizing medications, including antibiotics (tetracyclines, sulfonamides, quinolones), thiazide diuretics, antifungals, thiazide diuretics, amiodarone d History of melanoma d History of multiple nonmelanoma skin cancers (including syndromes that make patients prone to nonmelanoma skin cancers such as Lynch syndrome and Gorlin syndrome) 2. Write the home phototherapy prescription A. Determine the type of UV light to be used d NB-UVB- most commonly used; more efficacious then BB-UVB and better side-effect profile than PUVA B. Determine the type of unit to prescribe (Table II) d Cabinet unit: full-body surrounding unit can treat entire body surface with 1 treatment; shortest treatment time; highest cost d Multidimensional/cabinet unit: large body surface area affected; short treatment time; a good ‘‘sweet spot’’ between a panel unit and cabinet unit in terms of both cost and treatment time d Large/short panel unit: large body surface area affected; longer treatment time because of repeating treatment with different body surfaces facing light; short panel for children or adults with either only upper or lower body affected; limited space in home d Small panel unit: limited body surface area affected; palm/sole involvement; travel often; limited space in home d Targeted units: severe, recalcitrant localized plaques; intertriginous involvement; scalps involvement; easily portable C. Determine the number of lamps (if it is an option with the chosen device) D. Determine the treatment regimen d Determine the patient’s Fitzpatrick skin type through patient interview and physical examination 3. Complete the necessary paperwork for the selected home phototherapy supplier A. Daavlin (Bryan, OH): complete the home phototherapy order packet d Provider responsibilities B Doctor’s written order B 5-10 Pages of relevant chart notes demonstrating failed treatments d
Patient responsibilities B Home phototherapy patient order form B Assignment of benefits form B Terms and conditions of sale agreement B Make an enlarged copy of insurance card
d
Mail, fax, or e-mail the packet with the insurance card to Daavlin
B. National Biological Corp (Beachwood, OH): (all forms available on World Wide Web site) d Contact corporation to verify insurance benefits (via online form or telephone) d Provider responsibilities B Letter of medical need B Order form or a prescription d
Patient responsibilities B Insurance form B Insurance order packet B Sales agreement Continued
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Table I. Cont’d B B B B d
Privacy practices Assignment of benefits Terms of sales Make an enlarged copy of insurance card
Send paperwork to corporation
C. UVBioTek (Hudson Falls, NY): (see the UVBiotek checklist on their World Wide Web site) d Provider responsibilities B Prescription B Letter of medical necessity B Patient notes indicating treatments tried and their results d
Patient responsibilities B Sales agreement B HIPAA privacy statement B Patient responsibilities, bill of rights, and HIPAA consent B Patient information B Make an enlarged copy of insurance card
d
Send paperwork to UVBioTek
D. Solarc Systems Inc (Minesing, Ontario, Canada) d Provider responsibilities B Doctor’s letter of medical necessity (template on their World Wide Web site) B Patient’s letter to insurance company (template on their World Wide Web site) B Health care professional approval section of order form d
Patient responsibilities B Make the insurance company claim B Order the unit through the Solarc order form, which can be faxed, e-mailed, or mailed
4. After submitting the necessary paperwork to the chosen home phototherapy supplier A. The supplier takes care of the insurance claim (with the exception of Solarc) and informs the patient of the results B. If the patient is denied coverage for the unit, you can reapply for a different unit (eg, a multidimensional 3-panel unit rather than a cabinet unit) or submit an appeal letter C. If the patient is denied coverage or cannot afford the copay, advise the patient to speak with the home phototherapy supplier to discuss a payment plan D. Some of the units (eg, from National Biological Corp) may require the physician to provide the patient with the physician control code that will be supplied to the physician from the company
5. After the patient receives the home phototherapy unit A. Emphasize importance of patient following the agreed-upon treatment regimen d You may suggest a physician-patient contract d You may suggest the patient keep a treatment log to bring to each office visit that includes the dates and duration of treatment B. Emphasize the importance the patient follows the safety measures d Use safety goggles d Men should use a genital shield, such as an athletic support d Follow only the treatment regimen given d Do not allow other individuals to use their phototherapy unit C. Follow-up visits d Schedule follow-up visits about every 3 mo d Assess for disease improvement d Assess for adverse events (erythema, sun damage) BB, Broadband; HIPAA, Health Insurance Portability and Accountability Act; NB, narrowband; PUVA, psoralen plus ultraviolet A; UV, ultraviolet.
Daavlin UV Series
Description
Type of UV light
Dimensions, in, H3W3D
NB-UVB BB-UVB UVA
79 3 41.5 3 30.5
7 Series
6-ft Panel unit; available with 8, 10, or 12 lamps that come with side doors or 4 or 6 lamps with optional doors that are reflective panels
NB-UVB BB-UVB UVA
78 3 39.5 3 23.5 (With doors extended, on castors, free standing)
4 Series
4-ft Panel; available with 10 or 20 lamps
NB-UVB UVA UVA1 Blue
49.5 3 21.5 3 22 (With stand)
1 Series
Small, portable unit; 4 lamps; 180-degree lamp design
NB-UVB UVA UVA1 Blue
21.75 3 9.75 3 9.75
Levia
Console with a light-emitting hand piece; for scalp or spot treatment
UVB
10.75 (Height of device) 0.67 3 0.67 (Spot treatment area) 0.94 3 0.94 (Brush treatment area)
Option to be equipped with dosimetry to measure the intensity of light and adjust treatment; optional exposure-limiting software; timer; safety lock (PIN to operate the unit); platform raises users to the height of the lamps Option to be equipped with dosimetry to measure the intensity of light and adjust treatment; optional patient positioning sensor; optional exposure-limiting software; safety lock (PIN to operate the unit); can be mounted to a wall Option to be equipped with dosimetry to measure the intensity of light and adjust treatment; optional exposure-limiting software; acrylic shield over lamps; can be mounted to a wall Optional stand to pivot and rotate the unit; acrylic shield covering the lamps; optional exposurelimiting software; UV sensor to measure the intensity of light and adjust treatment Two attachments, 1 designed specifically for spot treatment and 1 designed for scalp treatment; nurse educator available to talk the patient through the first Continued
Anderson and Feldman 5
Full- body surrounding cabinet; walk-in unit; available with 12, 16, or 24 lamps
Special features
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Table II. Home phototherapy suppliers from the National Psoriasis Foundation and the units they supply10-13
Product
Description
M Series
Cabinet style designed specifically for treatment of hands and feet; available in 10, 6, and 4 lamps
DermaPal
Compact device for spot or scalp treatment
National Biological Corp Panosol 3D 3-Panel unit for full-body treatment; 10 lamps
Type of UV light
Dimensions, in, H3W3D
Special features
use; tracks treatment history for review by physician UV sensor to measure the NB-UVB (10 lamps or 4 lamps) 13.5 3 20.25 3 22 intensity of light and adjust UVA (10 lamps or 6 lamps) (Single unit with hood) treatment; optional exposure33.5 3 26 3 26 limiting software; timer; safety (Table unit) lock (PIN to operate the unit); acrylic shield over the lamps; hood can be removed so the base can be used as a small panel device Timer NB-UVB 2.75 3 9 3 5 UVA 8.25 3 1.75 (Wand size) 1 3 4.5 (Treatment area) NB-UVB UVA
NB-UVB (6 lamp 6-ft version and 8 lamp 2-ft version) BB-UVB (4 lamp version in 6- or 2-ft height) UVA (in 6 lamp 6-ft version or 8 lamp 2-ft version) NB-UVB
82 3 29.5 3 4.5 (With doors closed) 73 3 52 3 28 (With stand and doors open) 74.5 3 29.5 3 16.5 (6-ft Version on stand) 29.5 3 /29.5 3 11.5 (2-ft Version on stand)
Single panel; available in 6- and 2-ft heights; 6 lamps and 4 lamps available in 6-ft height; 8 lamps and 4 lamps available in 2-ft height
Foldalite III
Full-body surrounding cabinet; 16 or 32 lamps
Handisol II
Portable treatment unit; can be used horizontally, vertically, or angled for treatment of different areas; 4 lamps
NB-UVB
3 3 25 3 18
Hand/Foot II
Comes as a single unit with a hood; optional cart to house 2 units, 1 for hands and 1 for feet for simultaneous treatment; 8 lamps
NB-UVB BB-UVB UVA
12.75 3 24 3 20 (Single unit)
76 3 38 3 38 (Open) 76 3 56 3 9 (Closed)
Key-locked; timer with automatic lamp shutoff; emergency on/off switch High-efficiency reflector wings; key-locked; timer with automatic lamp shutoff; emergency on/off switch
Ke-locked; timer with automatic lamp shutoff; emergency on/ off switch Key-locked; timer with automatic lamp shutoff; emergency on/off switch; ventilating fan; acrylic shield over lamps Key-locked; timer with automatic lamp shutoff; emergency on/off switch; ventilating fan
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Panosol II panels
6 Anderson and Feldman
Table II. Cont’d
3.2 3 12.8 3 1.2
NB-UVB
86 3 22 3 5
NB-UVB
89 3 23 3 9
NB-UVB BB-UVB
83 3 38 3 8
Flat, portable light panel; comes with a UV shield to use specifically for hands and feet or use open for localized plaques
NB-UVB
5 3 37 3 18 (Closed) 18 3 37 3 18 (Open)
SolarC Systems Inc E-Series (E720-UVBNB and E720A-UVBNB)
Single panel (E720M) with option to add additional panels for a multidirectional unit; each panel has 2 lamps
NB-UVB
72 3 12.8 3 3 (Each panel)
SolRx 1000 Series
6-ft Panel; 10, 8, 6, 4 lamp units available
SolRx 500 Series
Tabletop device; 5, 3, and 2 lamp units available
100 Series handheld phototherapy
Handheld spot treatment device; 2 lamps
UV BioTek Single panel with decorative doors to Single panel conceal the lamps; available with 10, 8, (models 100B, 80B, 6, or 4 lamps 60B, and 40B) Multidirectional 3-Panel unit with decorative doors that conceal the lamps when not in use; 10 lamps Full body (model 4-Panel unit for a flexible configuration for 1600B and 800B) full-body exposure; 16 or 8 lamps Mobile-Lite
BB, Broadband; NB, narrowband; PIN, personal identification number; UV, ultraviolet.
NB-UVB (10, 8, 6, and 4 lamp units) BB-UVB (6 and 4 lamp units) NB-UVB
NB-UVB BB-UVB
72 3 29 3 3.5 6.5 3 24 3 13.5
3.5 3 7 3 2.25
Decorative door panels; reflector panels; acrylic shield over lamps Decorative door panels; acrylic shield over lamps Decorative door panels; acrylic shield over lamps; Accu-Safe timer; folds flat Acrylic shield over lamps
Expandable unit; must purchase ‘‘master’’ panel then may purchase additional ‘‘add-on’’ panels to connect to the master panel; timer on master panel; keyed switchlock; wire guard covering lamps Timer; keyed switchlock; wire guard covering lamps Small size allows for hand, foot, and spot treatments; removable mounting yoke; removable hood; timer; switchlock; wire guard over bulbs Includes a carrying case; includes aperture plates for precise localized treatment; positioning arm and UV-brush available; acrylic panel covering lamps; timer; switchlock
Anderson and Feldman 7
NB-UVB
Dermalight 90
Key-locked; timer with automatic lamp shutoff; emergency on/off switch Timer; UV checker to alert when the energy from the lamps is low
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4.1 3 7.5 3 2.8 (Folded) 4.1 3 15 3 2.8 (Open)
Portable phototherapy wand with multiple positions; comb attachment available for scalp treatment; 2 lamps Portable phototherapy wand with comb attachment for scalp treatment; 3 lamps
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NB-UVB
DermaLume 2X
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Table III. Dosing instructions for narrowband ultraviolet B based on Fitzpatrick skin type25,26
Fitzpatrick skin type
I II III IV V VI
Description of skin type
Always burns, never tans Burns easily, rarely tans May have a mild burn but tans Minimally burns, tans easily Rarely burns, tans dark (brown skin) Never burns (black skin)
Initial treatment dose, mJ/cm2
Suggested increase increments, mJ/cm2
130
15
220
25
260
40
330
45
350
60
400
65
and safer than psoralen plus UVA.10 Psoralen plus UVA may be more efficacious than NB-UVB, but can be associated with severe burning and is probably inappropriate for home use.2,8,10,15,16 NB-UVB will be the best choice for most patients. Type of unit to prescribe. There are multiple brands of home phototherapy units. As of October 2014, The National Psoriasis Foundation provides a list of 4 companies that sell home phototherapy equipment (http://www.psoriasis.org/about-psoria sis/treatments/phototherapy/uvb/home-equipment).17 Each company provides a variety of units including multidimensional full-body panels, single full-body panels, short panels, portable panels, and different varieties of target therapies (Table II). Many of the home light units come equipped with safety features (Table II).11-14 If a device with a UV sensor is purchased, it should be regularly calibrated or the initial irradiance should be noted and treatments may need to be adjusted for declines in intensity over time. The type and size of unit needed will depend on the extent of body surface area affected, space available to house the unit, and cost. For the great majority of patients, 3-dimensional type panel systems with wings provide a ‘‘sweet spot’’ because they are a compromise between cost and treatment time, as a cabinet unit would be significantly more expensive and a single-panel unit would not provide sufficient body coverage and require more time for treatment. Single panels have indications as well but are usually not as appropriate as a 3-dimensional type panel unit (Table I). Targeted phototherapy devices are an option for recalcitrant localized plaques and areas not exposed
well to panels, such as intertriginous and scalp plaques.18,19 Many of the handheld devices have an optional comb attachment to lift hair to target the scalp. When patients have many affected areas, self-administered use of these localized devices is generally not practical and may pose harm because of exposure of overlapping treated areas. The number of lamps (light bulbs) is an option for some of the devices. The more lamps a unit has, the more UV exposure it emits per unit time, allowing for shorter treatment times. Because the cost increases as the number of lamps increase, the patient has to weigh the time for treatment versus the cost. As a provider, this aspect needs to be considered because longer treatment times may lead to decreased adherence. For a phototherapy unit that emits 3 mW of power, for a patient with a Fitzpatrick skin type of III, their initial dose of 260 mJ would require 87 seconds of treatment (Table III), but increases to 4 minutes and 30 seconds for a unit that emits 1 mW of power. Treatment schedules for NB-UVB. Treatment schedules vary based on the type of light, prescribing physician, patient, severity, extent, and location of the disease. One approach for prescribing NBUVB phototherapy treatment is based on minimal erythema dose (MED). MED is determined by exposing small areas of the patient’s skin to increasing doses of UV light, usually with a template and handheld UV device. These areas are examined 24 to 48 hours later to determine the MED, the minimal duration of exposure that produced erythema.20 Phototherapy can be started at 0.5 to 0.7 of MED and then increased 5% to 20% with each treatment to maintain a mild erythema throughout treatment, while avoiding severe sunburn-like reactions.21-24 Because of the difficulty of determining MED, this method for determining a treatment schedule is not always used, especially with home phototherapy. A more common means to determine a treatment schedule for NB-UVB phototherapy is based on Fitzpatrick skin type: the patient’s skin color, likelihood to burn, and likelihood to tan (Table III).25-27 The patient should be advised the dose should be maintained at or just below the dose that causes a mild erythema. Therefore, the dose is increased at increments (Table III) until the patient experiences mild erythema after the treatment, then that current dose should be maintained or slightly decreased.15 Physicians should inform their patients the dose should not be increased if skin redness is detected. For both treatment regimens, treatment every other day or 3 times per week is commonly prescribed. Patients usually need 15 to 20 treatments to
Daavlin
Resources d
d d
National Biological Corp
d
d
d
Provider responsibilities
Home phototherapy order packet (http://www.daavlin.com/wpcontent/uploads/2012/03/HomeOrder-Packet.pdf ) Patient account specialist Online chat help
d
Corporation contact to verify insurance benefits via online form or telephone (http://www.natbio corp.com/contact141014.htm) Corporation forms (http://www. natbiocorp.com/insurance-guide. htm) Corporation provides online help through a contact form or via telephone
d
d
Doctor’s written order (serves as the letter of medical necessity and the prescription) $5 Pages of relevant patient notes
Patient responsibilities d
d d
d
d
Letter of medical need (sample on their World Wide Web site) Order form (on their World Wide Web site) or prescription
d d d d d d d
Home phototherapy patient order form Assignment of benefits form Terms and conditions of sale agreement Enlarged copy of insurance card Insurance form Insurance order packet Sales agreement Privacy practices Assignment of benefits Terms of sales Enlarged copy of insurance card
After paperwork is complete d
d
d d
d
d
UVBioTek
d
d
d
Solarc provides tips for insurance reimbursement (http://www.solarc systems.com/us_insurancetips.html)
HIPAA, Health Insurance Portability and Accountability Act.
d
d d
d d
Prescription (form on World Wide Web site) Letter of medical necessity Patient notes indicating treatments that have been tried and their results
d
Prescription Complete the health care professional approval section of order form
d
d d
d
d
Sales agreement HIPAA privacy statement Patient responsibilities, bill of rights, and HIPAA consent Enlarged copy of insurance card Make the claim to their insurance company Complete the order form
d
d
d
The paperwork is sent to corporation Corporation explains to the patient the various models available based on the prescription, follows up with the patient’s insurance company, contacts the patient with the approximate cost Corporation follows up with the physician’s office when the patient receives the unit Corporation follows up with the patient in 90 d to inquire about how they are doing The completed paperwork is e-mailed, faxed, or mailed to UVBioTek UVBioTek verifies insurance for the patient
After the patient has made the claim to their insurance company (unless they are not using their insurance) they complete the order form and fax, e-mail, or mail it to Solarc
Anderson and Feldman 9
Solarc Systems Inc
UVBioTek provides a checklist with all of the necessary forms (http://www.uvbiotek.com/patientprescription-forms/) Customer service
The home phototherapy order packet should be faxed, e-mailed, or mailed to Daavlin once completed Daavlin contacts the patient’s insurance company to determine coverage
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Table IV. Process of ordering a home phototherapy unit from Daavlin, National Biological Corp, UVBioTek, and Solarc10-13
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achieve at least a 50% improvement.21 In the absence of adverse events, treatment should continue until the patient is clear or no longer sees improvement.16 If the patient develops severe erythema with pain, blisters, or both, the phototherapy should be stopped and not restarted until the erythema resolves. The phototherapy should be re-initiated at 50% of the dose that caused the severe erythema. Patients need to be advised about the importance of using eye shields and, for men, a genital shield, such as an athletic support, during the phototherapy sessions. Potential side effects and their rates do not differ significantly between home phototherapy and outpatient phototherapy.6,28 Side effects include erythema (ranging from mild to severe), itching, herpes simplex virus infection, polymorphic light eruption, and blisters.6,28 Poor adherence, both to treatment sessions and office visits, is a potential problem with home and in-office phototherapy. Follow-up monitoring can assess adherence, the improvement of the psoriasis, and adverse events.9 Short-term adherence with the prescribed treatment regimens in home phototherapy is surprisingly good.29 To avoid potential side effects and poor adherence, the patient should be competent to operate the light unit and follow instructions. In addition, some clinicians may opt to prescribe a unit with safety features that limit exposures, units that track treatments and make it available to the provider (Table II), or require patients sign a contract and/or keep a phototherapy log.11 Dealing with obstacles Home phototherapy equipment is typically covered by the durable medical equipment benefit of health insurance plans. Durable medical equipment includes equipment for the home that is long-lasting, medically necessary, and not beneficial for an individual who is not sick. Many of the companies that provide home phototherapy equipment have personnel available, free of charge, to assist with getting insurance coverage for the unit. The necessary paperwork differs between each company, but overall it is similar (Table IV). A prescription and a letter of medical necessity (Fig 1, available at http://www. jaad.org) are needed, but the company may have a process that takes care of both in 1 document. The large majority of patients who get a home phototherapy device receive at least some coverage for the home phototherapy equipment from their insurance. Under Medicare, patients pay 20% of the Medicare-approved amount and Medicare pays the difference.30 The home phototherapy companies will often work with the
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patient and the insurance company to find options to help make the unit more affordable. For example, if the original claim is denied, the home phototherapy supplier can contact the insurance company and ask if an alternate unit would be covered, such as a 3-panel unit rather than a full-body cabinet. Appeal letters to the insurance company describing the low cost of phototherapy compared with biologics or prolonged courses of office treatments may be helpful. The home phototherapy supplier may also work with the patient to offer a payment plan and/ or discount the price if the insurance company was not helpful. If a patient does not have insurance but is interested in purchasing a home light unit, they can purchase one directly from any of the companies listed as long as they have a prescription from their physician.
DISCUSSION Phototherapy may be a good treatment option for many patients with psoriasis because of its efficacy, limited contraindications, and reasonable side-effect profile. To minimize some of the inconveniences associated with phototherapy, such as lost time from multiple office visits and lost money as a result of copays, home phototherapy is a good choice for many patients. Patients also report greater treatment satisfaction, which may improve compliance. Side effects with home phototherapy are not significantly different from inoffice phototherapy,6,28 but safety features that allow closer physician monitoring may become more widespread in future home phototherapy units. The process of purchasing a unit can be made easier on the provider and patient by working closely with a home phototherapy unit supplier to help navigate the process of getting insurance coverage for the unit or formulating a payment plan to ease the cost burden (Table I). REFERENCES 1. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58(5): 826-850. 2. Van Voorhees A, Feldman S, Koo J, Lebwohl M, Menter A. The psoriasis and psoriatic arthritis pocket guide. Portland, OR: National Psoriasis Foundation; 2009. 3. Lebwohl M. A clinician’s paradigm in the treatment of psoriasis. J Am Acad Dermatol. 2005;53(Suppl):S59-S69. 4. Yentzer BA, Gustafson CJ, Feldman SR. Explicit and implicit copayments for phototherapy: examining the cost of commuting. Dermatol Online J. 2013;19(6):18563. 5. Yentzer BA, Yelverton CB, Simpson GL, et al. Paradoxical effects of cost reduction measures in managed care
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17.
systems for treatment of severe psoriasis. Dermatol Online J. 2009;15(4):1. Koek MB, Buskens E, van WH, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicenter randomized controlled non-inferiority trial (PLUTO study). BMJ. 2009;338:b1542. Greist HM, Pearce DJ, Blauvelt M, Feldman SR. Resident education: effect of the sixth national psoriasis foundation chief residents’ meeting. J Cutan Med Surg. 2006;10(1): 16-20. Stern RS, Nichols KT, Vakeva LH. Malignant melanoma in patients treated for psoriasis with methoxsalen (psoralen) and ultraviolet A radiation (PUVA); the PUVA follow-up study. N Engl J Med. 1997;336(15):1041-1045. Bhutani T, Liao W. A practical approach to home UVB phototherapy for the treatment of generalized psoriasis. Pract Dermatol. 2010;7(2):31-35. Almutawa F, Thalib L, Hekman D, Sun Q, Hamzavi I, Lim HW. Efficacy of localized phototherapy and photodynamic therapy for psoriasis: a systematic review and meta-analysis. Photodermatol Photoimmunol Photomed. 2015;31:5-14. Daavlin. Daavlin: Phototherapy solutions for psoriasis and vitiligo. 2013. Available at: http://www.daavlin.com. Accessed October 30, 2014. National Biological. National Biological: The phototherapy experts! 2014. Available at: http://www.natbiocorp.com. Accessed October 30, 2014. UVBioTek. UVBioTek: The clear choice in skin treatment. Available at: http://www.uvbiotek.com. Accessed October 30, 2014. Solarc Phototherapy. SOLARC SYSTEMS INC. 2014. Available at: http://www.solarcsystems.com/us_main.html. Accessed October 30, 2014. Walters IB, Burack LH, Coven TR, Gilleaudeau P, Krueger JG. Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris. J Am Acad Dermatol. 1999;40(6 Pt 1):893-900. Lapolla W, Yentzer BA, Bagel J, Halvorson CR, Feldman SR. A review of phototherapy protocols for psoriasis treatment. J Am Acad Dermatol. 2011;64(5):936-949. National Psoriasis Foundation. Moderate to severe psoriasis: Home UVB equipment. March 2015. Available at: http://www.
18.
19. 20. 21. 22.
23.
24.
25.
26. 27. 28.
29.
30.
psoriasis.org/about-psoriasis/treatments/phototherapy/uvb/ home-equipment. Accessed October 11, 2014. Toll A, Velez-Gonzalez M, Gallardo F, Gilaberte M, Pujol RM. Treatment of localized persistent plaque psoriasis with incoherent narrowband ultraviolet B phototherapy. J Dermatolog Treat. 2005;16(3):165-168. Kaur M, Oliver B, Hu J, Feldman SR. Nonlaser UVB-targeted phototherapy treatment of psoriasis. Cutis. 2006;78(3):200-203. Heckman CJ, Chandler R, Kloss JD, et al. Minimal erythema dose (MED) testing. J Vis Exp. 2013;(75):e50175. Zanolli M. Phototherapy treatment of psoriasis today. J Am Acad Dermatol. 2003;49(Suppl):S78-S86. Kleinpenning MM, Smits T, Boezeman J, van de Kerkhof PC, Evers AW, Gerritsen MJ. Narrowband ultraviolet B therapy in psoriasis: randomized double-blind comparison of high-dose and low-dose irradiation regimens. Br J Dermatol. 2009;161(6): 1351-1356. Boztepe G, Akinci H, Sahin S, et al. In search of an optimum dose escalation for narrowband UVB phototherapy: is it time to quit 20% increments? J Am Acad Dermatol 2006;55(2): 269-271. Wainwright NJ, Dawe RS, Ferguson J. Narrowband ultraviolet B (TL-01) phototherapy for psoriasis: which incremental regimen? Br J Dermatol 1998;139(3):410-414. Schneider LA, Hinrichs R, Scharffetter-Kochanek K. Phototherapy and photochemotherapy. Clin Dermatol. 2008;26(5): 464-476. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869-871. Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J. 2010;16(2):1. Cameron H, Yule S, Dawe RS, Ibbotson SH, Moseley H, Ferguson J. Review of an established UK home phototherapy service 1998-2011: improving access to a cost-effective treatment for chronic skin disease. Public Health. 2014;128(4):317-324. Yentzer BA, Yelverton CB, Pearce DJ, et al. Adherence to acitretin and home narrowband ultraviolet B phototherapy in patients with psoriasis. J Am Acad Dermatol. 2008;59(4): 577-581. Medicare.gov. Your Medicare Coverage: Durable medical equipment (DME) coverage. Available at: http://www.medicare.gov/ coverage/durable-medical-equipment-coverage.html. Accessed October 20, 2015.
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Fig 1. Letter of medical necessity.
A guide to prescribing home phototherapy for patients with psoriasis: The appropriate patient, the type of unit, the treatment regimen, and the potential obstacles Kathryn L. Anderson, BS,a and Steven R. Feldman, MD, PhDa,b,c Winston-Salem, North Carolina Background: Ultraviolet B phototherapy is underused because of costs and inconvenience. Home phototherapy may alleviate these issues, but training is spotty, and many physicians are not comfortable prescribing home phototherapy. Objective: The purpose of this review is to provide a practical guide for recognizing appropriate patients, prescribing, and dealing with potential obstacles for home phototherapy treatment. Methods: Current guidelines for treatment of psoriasis were used to describe an appropriate patient for home phototherapy. Current literature and resources from phototherapy providers were reviewed to determine appropriate type of light, unit, treatment regimen, and how to navigate the insurance claim process. Results: Treatment schedules vary based on skin type. Home phototherapy companies provide various units suited for individual situations. Assistance can be used from suppliers to facilitate the process of obtaining a home phototherapy unit and navigating obstacles. Limitations: Phototherapy treatment varies on an individual basis, so this review serves only as a guide. Conclusion: Home phototherapy is a suitable treatment for many patients for whom office-based phototherapy is not accessible. Home phototherapy companies simplify the process by providing assistance for prescribing home light units. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2015.02.003.) Key words: broadband ultraviolet B; home phototherapy; insurance; narrowband ultraviolet B; phototherapy; psoriasis; ultraviolet A.
U
ltraviolet (UV) B phototherapy is a first-line treatment for extensive psoriasis and is a second-line treatment for localized psoriasis not responding to topical medications.1-3 Phototherapy, however, is often underused because From the Center for Dermatology Research, Department of Dermatology,a Department of Pathology,b and Department of Public Health Sciences,c Wake Forest School of Medicine. The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories LP. Disclosure: Dr Feldman is a speaker for Janssen and Taro. He is a consultant and speaker for Galderma, Stiefel/GlaxoSmithKline, Abbott Labs, Leo Pharma Inc, and Novartis. He has received grants from Galderma, Janssen, Abbott Labs, Amgen, Stiefel/GlaxoSmithKline, Celgene, and Anacor. He is a consultant for Amgen, Baxter, Caremark, Gerson Lehrman Group, Guidepoint Global, Hanall Pharmaceutical Co Ltd, Kikaku, Lilly, Merck & Co Inc, Merz Pharmaceuticals, Mylan, Novartis Pharmaceuticals, Pfizer Inc, Qurient, Suncare Research, and Xenoport. He is on an
Abbreviations used: MED: NB: UV:
minimal erythema dose narrowband ultraviolet
advisory board for Pfizer Inc, Abbvie, and Celgene. He is the founder and holds stock in Causa Research and holds stock and is majority owner in Medical Quality Enhancement Corp. He receives Royalties from UpToDate and Xlibris. Ms Anderson has no conflicts of interest to declare. Accepted for publication February 1, 2015. Reprint requests: Kathryn L. Anderson, BS, Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071. E-mail: [email protected]. Published online March 5, 2015. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.02.003
1
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of prohibitive copayment costs or inconvenience to office or home-based phototherapy (Table I).1,8 the patient of office-based phototherapy treatments, Unlike many systemic treatments for moderate to particularly in the United States.4,5 Phototherapy may severe psoriasis, phototherapy is a relatively safe treatment option for immunosuppressed be the lowest cost option compared with biologics, patients, patients with ongoing infections, patients but not necessarily from the patients’ standpoint currently on medications that would pose a pharmabecause of multiple copays, driving time, driving cologic interaction with systemic medications, paexpenses, lost wages, cost of equipment, or a tients with comorbidities combination of these.5 limiting the medication opInconvenience and cost can CAPSULE SUMMARY tions, children, and women be minimized by prescribing who are pregnant or breasta home light unit.4 In addiHome phototherapy is an efficacious and feeding.1,2 tion, home phototherapy can reasonably safe treatment for psoriasis, be as effective as officeHome phototherapy is but training in prescribing it is poor. based phototherapy, while well suited for patients who Prescribing home phototherapy can be increasing patient satisfacare unable to attend outpastreamlined with the assistance of home tion with treatment.6 tient phototherapy because Resident training for using light unit providers. of distance from phototherphototherapy as treatment is apy site, cost of travel and Communication among patient, lacking.7 The purpose of this lost wages, or time conflicts.9 physician, phototherapy provider, and review is to provide a pracHome phototherapy can be insurance carrier will facilitate the tical guide for recognizing used for long-term mainteavailability of home phototherapy. the appropriate patient for nance in patients who have home light treatment, precleared using office-based scribing home light treatphototherapy (in which case the patient should ment, and dealing with potential obstacles, such as already have a good understanding of the proaffordability and insurance issues. cedures, side effects, and signs of adequate treatment) or de novo in patients who are just starting a METHODS phototherapy regimen.9 Home phototherapy is also The guidelines for treatment of psoriasis puban appropriate treatment for individuals with locallished by Journal of the American Academy of ized lesions who have failed topical treatments, Dermatology,1 the guide for treatment from The those would prefer to not use topical treatments, or National Psoriasis Foundation,2 and ‘‘A Clinician’s as an adjunctive treatment.10 There are a variety of 3 Paradigm in the Treatment of Psoriasis’’ were used spot-treatment home phototherapy devices deto describe an appropriate patient for home photosigned for localized lesions, scalp lesions, and palms therapy. The phototherapy companies to include in and soles.11-14 this review were determined based on those listed by Many patients may benefit from a trial of photothe National Psoriasis Foundation via their World therapy before moving on to other systemic treatWide Web site (http://www.psoriasis.org/aboutments that may be associated with more risks, higher psoriasis/treatments/phototherapy/uvb/home-equip costs, or both. To make phototherapy available to a ment). World Wide Web sites, catalogs, and larger number of patients, home phototherapy may personnel from phototherapy unit providers were be a favorable option. used to gather information regarding their products and how to navigate the insurance claim process. Prescribing the appropriate phototherapy Current literature was reviewed to recommend treatment treatment regimens for home phototherapy units, When prescribing home phototherapy, the preincluding type of light, type of unit, and treatment scription should indicate the type of UV light to be schedule. used and the type of light unit. Also, the treatment schedule needs to be determined and communicated clearly to the patient. RESULTS Type of UV light to prescribe. Broadband Recognizing the appropriate patient to receive UVB, narrowband (NB) UVB, and psoralen plus home phototherapy UVA can all be used to treat psoriasis. Randomized, Phototherapy is a first-line treatment for psoriasis, blinded trials have been done comparing the particularly if too extensive to be treated with 3 options as a form of in-office phototherapy. topicals alone (often defined by [10% body surface NB-UVB is more efficacious than broadband UVB area).1-3 There are very few contraindications for d
d
d
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Anderson and Feldman 3
Table I. Checklist for providers prescribing home light treatment 1. Determine if the patient is appropriate for phototherapy A. Strongly consider contraindications: d History of photosensitivity disorder, including xeroderma pigmentosum, lupus erythematosus, dermatomyositis, and porphyria disorders d Use of photosensitizing medications, including antibiotics (tetracyclines, sulfonamides, quinolones), thiazide diuretics, antifungals, thiazide diuretics, amiodarone d History of melanoma d History of multiple nonmelanoma skin cancers (including syndromes that make patients prone to nonmelanoma skin cancers such as Lynch syndrome and Gorlin syndrome) 2. Write the home phototherapy prescription A. Determine the type of UV light to be used d NB-UVB- most commonly used; more efficacious then BB-UVB and better side-effect profile than PUVA B. Determine the type of unit to prescribe (Table II) d Cabinet unit: full-body surrounding unit can treat entire body surface with 1 treatment; shortest treatment time; highest cost d Multidimensional/cabinet unit: large body surface area affected; short treatment time; a good ‘‘sweet spot’’ between a panel unit and cabinet unit in terms of both cost and treatment time d Large/short panel unit: large body surface area affected; longer treatment time because of repeating treatment with different body surfaces facing light; short panel for children or adults with either only upper or lower body affected; limited space in home d Small panel unit: limited body surface area affected; palm/sole involvement; travel often; limited space in home d Targeted units: severe, recalcitrant localized plaques; intertriginous involvement; scalps involvement; easily portable C. Determine the number of lamps (if it is an option with the chosen device) D. Determine the treatment regimen d Determine the patient’s Fitzpatrick skin type through patient interview and physical examination 3. Complete the necessary paperwork for the selected home phototherapy supplier A. Daavlin (Bryan, OH): complete the home phototherapy order packet d Provider responsibilities B Doctor’s written order B 5-10 Pages of relevant chart notes demonstrating failed treatments d
Patient responsibilities B Home phototherapy patient order form B Assignment of benefits form B Terms and conditions of sale agreement B Make an enlarged copy of insurance card
d
Mail, fax, or e-mail the packet with the insurance card to Daavlin
B. National Biological Corp (Beachwood, OH): (all forms available on World Wide Web site) d Contact corporation to verify insurance benefits (via online form or telephone) d Provider responsibilities B Letter of medical need B Order form or a prescription d
Patient responsibilities B Insurance form B Insurance order packet B Sales agreement Continued
4 Anderson and Feldman
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Table I. Cont’d B B B B d
Privacy practices Assignment of benefits Terms of sales Make an enlarged copy of insurance card
Send paperwork to corporation
C. UVBioTek (Hudson Falls, NY): (see the UVBiotek checklist on their World Wide Web site) d Provider responsibilities B Prescription B Letter of medical necessity B Patient notes indicating treatments tried and their results d
Patient responsibilities B Sales agreement B HIPAA privacy statement B Patient responsibilities, bill of rights, and HIPAA consent B Patient information B Make an enlarged copy of insurance card
d
Send paperwork to UVBioTek
D. Solarc Systems Inc (Minesing, Ontario, Canada) d Provider responsibilities B Doctor’s letter of medical necessity (template on their World Wide Web site) B Patient’s letter to insurance company (template on their World Wide Web site) B Health care professional approval section of order form d
Patient responsibilities B Make the insurance company claim B Order the unit through the Solarc order form, which can be faxed, e-mailed, or mailed
4. After submitting the necessary paperwork to the chosen home phototherapy supplier A. The supplier takes care of the insurance claim (with the exception of Solarc) and informs the patient of the results B. If the patient is denied coverage for the unit, you can reapply for a different unit (eg, a multidimensional 3-panel unit rather than a cabinet unit) or submit an appeal letter C. If the patient is denied coverage or cannot afford the copay, advise the patient to speak with the home phototherapy supplier to discuss a payment plan D. Some of the units (eg, from National Biological Corp) may require the physician to provide the patient with the physician control code that will be supplied to the physician from the company
5. After the patient receives the home phototherapy unit A. Emphasize importance of patient following the agreed-upon treatment regimen d You may suggest a physician-patient contract d You may suggest the patient keep a treatment log to bring to each office visit that includes the dates and duration of treatment B. Emphasize the importance the patient follows the safety measures d Use safety goggles d Men should use a genital shield, such as an athletic support d Follow only the treatment regimen given d Do not allow other individuals to use their phototherapy unit C. Follow-up visits d Schedule follow-up visits about every 3 mo d Assess for disease improvement d Assess for adverse events (erythema, sun damage) BB, Broadband; HIPAA, Health Insurance Portability and Accountability Act; NB, narrowband; PUVA, psoralen plus ultraviolet A; UV, ultraviolet.
Daavlin UV Series
Description
Type of UV light
Dimensions, in, H3W3D
NB-UVB BB-UVB UVA
79 3 41.5 3 30.5
7 Series
6-ft Panel unit; available with 8, 10, or 12 lamps that come with side doors or 4 or 6 lamps with optional doors that are reflective panels
NB-UVB BB-UVB UVA
78 3 39.5 3 23.5 (With doors extended, on castors, free standing)
4 Series
4-ft Panel; available with 10 or 20 lamps
NB-UVB UVA UVA1 Blue
49.5 3 21.5 3 22 (With stand)
1 Series
Small, portable unit; 4 lamps; 180-degree lamp design
NB-UVB UVA UVA1 Blue
21.75 3 9.75 3 9.75
Levia
Console with a light-emitting hand piece; for scalp or spot treatment
UVB
10.75 (Height of device) 0.67 3 0.67 (Spot treatment area) 0.94 3 0.94 (Brush treatment area)
Option to be equipped with dosimetry to measure the intensity of light and adjust treatment; optional exposure-limiting software; timer; safety lock (PIN to operate the unit); platform raises users to the height of the lamps Option to be equipped with dosimetry to measure the intensity of light and adjust treatment; optional patient positioning sensor; optional exposure-limiting software; safety lock (PIN to operate the unit); can be mounted to a wall Option to be equipped with dosimetry to measure the intensity of light and adjust treatment; optional exposure-limiting software; acrylic shield over lamps; can be mounted to a wall Optional stand to pivot and rotate the unit; acrylic shield covering the lamps; optional exposurelimiting software; UV sensor to measure the intensity of light and adjust treatment Two attachments, 1 designed specifically for spot treatment and 1 designed for scalp treatment; nurse educator available to talk the patient through the first Continued
Anderson and Feldman 5
Full- body surrounding cabinet; walk-in unit; available with 12, 16, or 24 lamps
Special features
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Table II. Home phototherapy suppliers from the National Psoriasis Foundation and the units they supply10-13
Product
Description
M Series
Cabinet style designed specifically for treatment of hands and feet; available in 10, 6, and 4 lamps
DermaPal
Compact device for spot or scalp treatment
National Biological Corp Panosol 3D 3-Panel unit for full-body treatment; 10 lamps
Type of UV light
Dimensions, in, H3W3D
Special features
use; tracks treatment history for review by physician UV sensor to measure the NB-UVB (10 lamps or 4 lamps) 13.5 3 20.25 3 22 intensity of light and adjust UVA (10 lamps or 6 lamps) (Single unit with hood) treatment; optional exposure33.5 3 26 3 26 limiting software; timer; safety (Table unit) lock (PIN to operate the unit); acrylic shield over the lamps; hood can be removed so the base can be used as a small panel device Timer NB-UVB 2.75 3 9 3 5 UVA 8.25 3 1.75 (Wand size) 1 3 4.5 (Treatment area) NB-UVB UVA
NB-UVB (6 lamp 6-ft version and 8 lamp 2-ft version) BB-UVB (4 lamp version in 6- or 2-ft height) UVA (in 6 lamp 6-ft version or 8 lamp 2-ft version) NB-UVB
82 3 29.5 3 4.5 (With doors closed) 73 3 52 3 28 (With stand and doors open) 74.5 3 29.5 3 16.5 (6-ft Version on stand) 29.5 3 /29.5 3 11.5 (2-ft Version on stand)
Single panel; available in 6- and 2-ft heights; 6 lamps and 4 lamps available in 6-ft height; 8 lamps and 4 lamps available in 2-ft height
Foldalite III
Full-body surrounding cabinet; 16 or 32 lamps
Handisol II
Portable treatment unit; can be used horizontally, vertically, or angled for treatment of different areas; 4 lamps
NB-UVB
3 3 25 3 18
Hand/Foot II
Comes as a single unit with a hood; optional cart to house 2 units, 1 for hands and 1 for feet for simultaneous treatment; 8 lamps
NB-UVB BB-UVB UVA
12.75 3 24 3 20 (Single unit)
76 3 38 3 38 (Open) 76 3 56 3 9 (Closed)
Key-locked; timer with automatic lamp shutoff; emergency on/off switch High-efficiency reflector wings; key-locked; timer with automatic lamp shutoff; emergency on/off switch
Ke-locked; timer with automatic lamp shutoff; emergency on/ off switch Key-locked; timer with automatic lamp shutoff; emergency on/off switch; ventilating fan; acrylic shield over lamps Key-locked; timer with automatic lamp shutoff; emergency on/off switch; ventilating fan
n 2015
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Panosol II panels
6 Anderson and Feldman
Table II. Cont’d
3.2 3 12.8 3 1.2
NB-UVB
86 3 22 3 5
NB-UVB
89 3 23 3 9
NB-UVB BB-UVB
83 3 38 3 8
Flat, portable light panel; comes with a UV shield to use specifically for hands and feet or use open for localized plaques
NB-UVB
5 3 37 3 18 (Closed) 18 3 37 3 18 (Open)
SolarC Systems Inc E-Series (E720-UVBNB and E720A-UVBNB)
Single panel (E720M) with option to add additional panels for a multidirectional unit; each panel has 2 lamps
NB-UVB
72 3 12.8 3 3 (Each panel)
SolRx 1000 Series
6-ft Panel; 10, 8, 6, 4 lamp units available
SolRx 500 Series
Tabletop device; 5, 3, and 2 lamp units available
100 Series handheld phototherapy
Handheld spot treatment device; 2 lamps
UV BioTek Single panel with decorative doors to Single panel conceal the lamps; available with 10, 8, (models 100B, 80B, 6, or 4 lamps 60B, and 40B) Multidirectional 3-Panel unit with decorative doors that conceal the lamps when not in use; 10 lamps Full body (model 4-Panel unit for a flexible configuration for 1600B and 800B) full-body exposure; 16 or 8 lamps Mobile-Lite
BB, Broadband; NB, narrowband; PIN, personal identification number; UV, ultraviolet.
NB-UVB (10, 8, 6, and 4 lamp units) BB-UVB (6 and 4 lamp units) NB-UVB
NB-UVB BB-UVB
72 3 29 3 3.5 6.5 3 24 3 13.5
3.5 3 7 3 2.25
Decorative door panels; reflector panels; acrylic shield over lamps Decorative door panels; acrylic shield over lamps Decorative door panels; acrylic shield over lamps; Accu-Safe timer; folds flat Acrylic shield over lamps
Expandable unit; must purchase ‘‘master’’ panel then may purchase additional ‘‘add-on’’ panels to connect to the master panel; timer on master panel; keyed switchlock; wire guard covering lamps Timer; keyed switchlock; wire guard covering lamps Small size allows for hand, foot, and spot treatments; removable mounting yoke; removable hood; timer; switchlock; wire guard over bulbs Includes a carrying case; includes aperture plates for precise localized treatment; positioning arm and UV-brush available; acrylic panel covering lamps; timer; switchlock
Anderson and Feldman 7
NB-UVB
Dermalight 90
Key-locked; timer with automatic lamp shutoff; emergency on/off switch Timer; UV checker to alert when the energy from the lamps is low
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4.1 3 7.5 3 2.8 (Folded) 4.1 3 15 3 2.8 (Open)
Portable phototherapy wand with multiple positions; comb attachment available for scalp treatment; 2 lamps Portable phototherapy wand with comb attachment for scalp treatment; 3 lamps
VOLUME jj, NUMBER j
NB-UVB
DermaLume 2X
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Table III. Dosing instructions for narrowband ultraviolet B based on Fitzpatrick skin type25,26
Fitzpatrick skin type
I II III IV V VI
Description of skin type
Always burns, never tans Burns easily, rarely tans May have a mild burn but tans Minimally burns, tans easily Rarely burns, tans dark (brown skin) Never burns (black skin)
Initial treatment dose, mJ/cm2
Suggested increase increments, mJ/cm2
130
15
220
25
260
40
330
45
350
60
400
65
and safer than psoralen plus UVA.10 Psoralen plus UVA may be more efficacious than NB-UVB, but can be associated with severe burning and is probably inappropriate for home use.2,8,10,15,16 NB-UVB will be the best choice for most patients. Type of unit to prescribe. There are multiple brands of home phototherapy units. As of October 2014, The National Psoriasis Foundation provides a list of 4 companies that sell home phototherapy equipment (http://www.psoriasis.org/about-psoria sis/treatments/phototherapy/uvb/home-equipment).17 Each company provides a variety of units including multidimensional full-body panels, single full-body panels, short panels, portable panels, and different varieties of target therapies (Table II). Many of the home light units come equipped with safety features (Table II).11-14 If a device with a UV sensor is purchased, it should be regularly calibrated or the initial irradiance should be noted and treatments may need to be adjusted for declines in intensity over time. The type and size of unit needed will depend on the extent of body surface area affected, space available to house the unit, and cost. For the great majority of patients, 3-dimensional type panel systems with wings provide a ‘‘sweet spot’’ because they are a compromise between cost and treatment time, as a cabinet unit would be significantly more expensive and a single-panel unit would not provide sufficient body coverage and require more time for treatment. Single panels have indications as well but are usually not as appropriate as a 3-dimensional type panel unit (Table I). Targeted phototherapy devices are an option for recalcitrant localized plaques and areas not exposed
well to panels, such as intertriginous and scalp plaques.18,19 Many of the handheld devices have an optional comb attachment to lift hair to target the scalp. When patients have many affected areas, self-administered use of these localized devices is generally not practical and may pose harm because of exposure of overlapping treated areas. The number of lamps (light bulbs) is an option for some of the devices. The more lamps a unit has, the more UV exposure it emits per unit time, allowing for shorter treatment times. Because the cost increases as the number of lamps increase, the patient has to weigh the time for treatment versus the cost. As a provider, this aspect needs to be considered because longer treatment times may lead to decreased adherence. For a phototherapy unit that emits 3 mW of power, for a patient with a Fitzpatrick skin type of III, their initial dose of 260 mJ would require 87 seconds of treatment (Table III), but increases to 4 minutes and 30 seconds for a unit that emits 1 mW of power. Treatment schedules for NB-UVB. Treatment schedules vary based on the type of light, prescribing physician, patient, severity, extent, and location of the disease. One approach for prescribing NBUVB phototherapy treatment is based on minimal erythema dose (MED). MED is determined by exposing small areas of the patient’s skin to increasing doses of UV light, usually with a template and handheld UV device. These areas are examined 24 to 48 hours later to determine the MED, the minimal duration of exposure that produced erythema.20 Phototherapy can be started at 0.5 to 0.7 of MED and then increased 5% to 20% with each treatment to maintain a mild erythema throughout treatment, while avoiding severe sunburn-like reactions.21-24 Because of the difficulty of determining MED, this method for determining a treatment schedule is not always used, especially with home phototherapy. A more common means to determine a treatment schedule for NB-UVB phototherapy is based on Fitzpatrick skin type: the patient’s skin color, likelihood to burn, and likelihood to tan (Table III).25-27 The patient should be advised the dose should be maintained at or just below the dose that causes a mild erythema. Therefore, the dose is increased at increments (Table III) until the patient experiences mild erythema after the treatment, then that current dose should be maintained or slightly decreased.15 Physicians should inform their patients the dose should not be increased if skin redness is detected. For both treatment regimens, treatment every other day or 3 times per week is commonly prescribed. Patients usually need 15 to 20 treatments to
Daavlin
Resources d
d d
National Biological Corp
d
d
d
Provider responsibilities
Home phototherapy order packet (http://www.daavlin.com/wpcontent/uploads/2012/03/HomeOrder-Packet.pdf ) Patient account specialist Online chat help
d
Corporation contact to verify insurance benefits via online form or telephone (http://www.natbio corp.com/contact141014.htm) Corporation forms (http://www. natbiocorp.com/insurance-guide. htm) Corporation provides online help through a contact form or via telephone
d
d
Doctor’s written order (serves as the letter of medical necessity and the prescription) $5 Pages of relevant patient notes
Patient responsibilities d
d d
d
d
Letter of medical need (sample on their World Wide Web site) Order form (on their World Wide Web site) or prescription
d d d d d d d
Home phototherapy patient order form Assignment of benefits form Terms and conditions of sale agreement Enlarged copy of insurance card Insurance form Insurance order packet Sales agreement Privacy practices Assignment of benefits Terms of sales Enlarged copy of insurance card
After paperwork is complete d
d
d d
d
d
UVBioTek
d
d
d
Solarc provides tips for insurance reimbursement (http://www.solarc systems.com/us_insurancetips.html)
HIPAA, Health Insurance Portability and Accountability Act.
d
d d
d d
Prescription (form on World Wide Web site) Letter of medical necessity Patient notes indicating treatments that have been tried and their results
d
Prescription Complete the health care professional approval section of order form
d
d d
d
d
Sales agreement HIPAA privacy statement Patient responsibilities, bill of rights, and HIPAA consent Enlarged copy of insurance card Make the claim to their insurance company Complete the order form
d
d
d
The paperwork is sent to corporation Corporation explains to the patient the various models available based on the prescription, follows up with the patient’s insurance company, contacts the patient with the approximate cost Corporation follows up with the physician’s office when the patient receives the unit Corporation follows up with the patient in 90 d to inquire about how they are doing The completed paperwork is e-mailed, faxed, or mailed to UVBioTek UVBioTek verifies insurance for the patient
After the patient has made the claim to their insurance company (unless they are not using their insurance) they complete the order form and fax, e-mail, or mail it to Solarc
Anderson and Feldman 9
Solarc Systems Inc
UVBioTek provides a checklist with all of the necessary forms (http://www.uvbiotek.com/patientprescription-forms/) Customer service
The home phototherapy order packet should be faxed, e-mailed, or mailed to Daavlin once completed Daavlin contacts the patient’s insurance company to determine coverage
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Company
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Table IV. Process of ordering a home phototherapy unit from Daavlin, National Biological Corp, UVBioTek, and Solarc10-13
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achieve at least a 50% improvement.21 In the absence of adverse events, treatment should continue until the patient is clear or no longer sees improvement.16 If the patient develops severe erythema with pain, blisters, or both, the phototherapy should be stopped and not restarted until the erythema resolves. The phototherapy should be re-initiated at 50% of the dose that caused the severe erythema. Patients need to be advised about the importance of using eye shields and, for men, a genital shield, such as an athletic support, during the phototherapy sessions. Potential side effects and their rates do not differ significantly between home phototherapy and outpatient phototherapy.6,28 Side effects include erythema (ranging from mild to severe), itching, herpes simplex virus infection, polymorphic light eruption, and blisters.6,28 Poor adherence, both to treatment sessions and office visits, is a potential problem with home and in-office phototherapy. Follow-up monitoring can assess adherence, the improvement of the psoriasis, and adverse events.9 Short-term adherence with the prescribed treatment regimens in home phototherapy is surprisingly good.29 To avoid potential side effects and poor adherence, the patient should be competent to operate the light unit and follow instructions. In addition, some clinicians may opt to prescribe a unit with safety features that limit exposures, units that track treatments and make it available to the provider (Table II), or require patients sign a contract and/or keep a phototherapy log.11 Dealing with obstacles Home phototherapy equipment is typically covered by the durable medical equipment benefit of health insurance plans. Durable medical equipment includes equipment for the home that is long-lasting, medically necessary, and not beneficial for an individual who is not sick. Many of the companies that provide home phototherapy equipment have personnel available, free of charge, to assist with getting insurance coverage for the unit. The necessary paperwork differs between each company, but overall it is similar (Table IV). A prescription and a letter of medical necessity (Fig 1, available at http://www. jaad.org) are needed, but the company may have a process that takes care of both in 1 document. The large majority of patients who get a home phototherapy device receive at least some coverage for the home phototherapy equipment from their insurance. Under Medicare, patients pay 20% of the Medicare-approved amount and Medicare pays the difference.30 The home phototherapy companies will often work with the
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patient and the insurance company to find options to help make the unit more affordable. For example, if the original claim is denied, the home phototherapy supplier can contact the insurance company and ask if an alternate unit would be covered, such as a 3-panel unit rather than a full-body cabinet. Appeal letters to the insurance company describing the low cost of phototherapy compared with biologics or prolonged courses of office treatments may be helpful. The home phototherapy supplier may also work with the patient to offer a payment plan and/ or discount the price if the insurance company was not helpful. If a patient does not have insurance but is interested in purchasing a home light unit, they can purchase one directly from any of the companies listed as long as they have a prescription from their physician.
DISCUSSION Phototherapy may be a good treatment option for many patients with psoriasis because of its efficacy, limited contraindications, and reasonable side-effect profile. To minimize some of the inconveniences associated with phototherapy, such as lost time from multiple office visits and lost money as a result of copays, home phototherapy is a good choice for many patients. Patients also report greater treatment satisfaction, which may improve compliance. Side effects with home phototherapy are not significantly different from inoffice phototherapy,6,28 but safety features that allow closer physician monitoring may become more widespread in future home phototherapy units. The process of purchasing a unit can be made easier on the provider and patient by working closely with a home phototherapy unit supplier to help navigate the process of getting insurance coverage for the unit or formulating a payment plan to ease the cost burden (Table I). REFERENCES 1. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58(5): 826-850. 2. Van Voorhees A, Feldman S, Koo J, Lebwohl M, Menter A. The psoriasis and psoriatic arthritis pocket guide. Portland, OR: National Psoriasis Foundation; 2009. 3. Lebwohl M. A clinician’s paradigm in the treatment of psoriasis. J Am Acad Dermatol. 2005;53(Suppl):S59-S69. 4. Yentzer BA, Gustafson CJ, Feldman SR. Explicit and implicit copayments for phototherapy: examining the cost of commuting. Dermatol Online J. 2013;19(6):18563. 5. Yentzer BA, Yelverton CB, Simpson GL, et al. Paradoxical effects of cost reduction measures in managed care
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systems for treatment of severe psoriasis. Dermatol Online J. 2009;15(4):1. Koek MB, Buskens E, van WH, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicenter randomized controlled non-inferiority trial (PLUTO study). BMJ. 2009;338:b1542. Greist HM, Pearce DJ, Blauvelt M, Feldman SR. Resident education: effect of the sixth national psoriasis foundation chief residents’ meeting. J Cutan Med Surg. 2006;10(1): 16-20. Stern RS, Nichols KT, Vakeva LH. Malignant melanoma in patients treated for psoriasis with methoxsalen (psoralen) and ultraviolet A radiation (PUVA); the PUVA follow-up study. N Engl J Med. 1997;336(15):1041-1045. Bhutani T, Liao W. A practical approach to home UVB phototherapy for the treatment of generalized psoriasis. Pract Dermatol. 2010;7(2):31-35. Almutawa F, Thalib L, Hekman D, Sun Q, Hamzavi I, Lim HW. Efficacy of localized phototherapy and photodynamic therapy for psoriasis: a systematic review and meta-analysis. Photodermatol Photoimmunol Photomed. 2015;31:5-14. Daavlin. Daavlin: Phototherapy solutions for psoriasis and vitiligo. 2013. Available at: http://www.daavlin.com. Accessed October 30, 2014. National Biological. National Biological: The phototherapy experts! 2014. Available at: http://www.natbiocorp.com. Accessed October 30, 2014. UVBioTek. UVBioTek: The clear choice in skin treatment. Available at: http://www.uvbiotek.com. Accessed October 30, 2014. Solarc Phototherapy. SOLARC SYSTEMS INC. 2014. Available at: http://www.solarcsystems.com/us_main.html. Accessed October 30, 2014. Walters IB, Burack LH, Coven TR, Gilleaudeau P, Krueger JG. Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris. J Am Acad Dermatol. 1999;40(6 Pt 1):893-900. Lapolla W, Yentzer BA, Bagel J, Halvorson CR, Feldman SR. A review of phototherapy protocols for psoriasis treatment. J Am Acad Dermatol. 2011;64(5):936-949. National Psoriasis Foundation. Moderate to severe psoriasis: Home UVB equipment. March 2015. Available at: http://www.
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psoriasis.org/about-psoriasis/treatments/phototherapy/uvb/ home-equipment. Accessed October 11, 2014. Toll A, Velez-Gonzalez M, Gallardo F, Gilaberte M, Pujol RM. Treatment of localized persistent plaque psoriasis with incoherent narrowband ultraviolet B phototherapy. J Dermatolog Treat. 2005;16(3):165-168. Kaur M, Oliver B, Hu J, Feldman SR. Nonlaser UVB-targeted phototherapy treatment of psoriasis. Cutis. 2006;78(3):200-203. Heckman CJ, Chandler R, Kloss JD, et al. Minimal erythema dose (MED) testing. J Vis Exp. 2013;(75):e50175. Zanolli M. Phototherapy treatment of psoriasis today. J Am Acad Dermatol. 2003;49(Suppl):S78-S86. Kleinpenning MM, Smits T, Boezeman J, van de Kerkhof PC, Evers AW, Gerritsen MJ. Narrowband ultraviolet B therapy in psoriasis: randomized double-blind comparison of high-dose and low-dose irradiation regimens. Br J Dermatol. 2009;161(6): 1351-1356. Boztepe G, Akinci H, Sahin S, et al. In search of an optimum dose escalation for narrowband UVB phototherapy: is it time to quit 20% increments? J Am Acad Dermatol 2006;55(2): 269-271. Wainwright NJ, Dawe RS, Ferguson J. Narrowband ultraviolet B (TL-01) phototherapy for psoriasis: which incremental regimen? Br J Dermatol 1998;139(3):410-414. Schneider LA, Hinrichs R, Scharffetter-Kochanek K. Phototherapy and photochemotherapy. Clin Dermatol. 2008;26(5): 464-476. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869-871. Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J. 2010;16(2):1. Cameron H, Yule S, Dawe RS, Ibbotson SH, Moseley H, Ferguson J. Review of an established UK home phototherapy service 1998-2011: improving access to a cost-effective treatment for chronic skin disease. Public Health. 2014;128(4):317-324. Yentzer BA, Yelverton CB, Pearce DJ, et al. Adherence to acitretin and home narrowband ultraviolet B phototherapy in patients with psoriasis. J Am Acad Dermatol. 2008;59(4): 577-581. Medicare.gov. Your Medicare Coverage: Durable medical equipment (DME) coverage. Available at: http://www.medicare.gov/ coverage/durable-medical-equipment-coverage.html. Accessed October 20, 2015.
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Fig 1. Letter of medical necessity.
