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Access Details: Free Access Publisher: Taylor & Francis Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Publication details, including instructions for authors and subscription information: Phototherapy with Narrowband vs Broadband UVB Mark Berneburg a; Martin Röcken a; Frauke Benedix a a Department of Dermatology, Eberhard Karls University. Tuebingen. Germany To cite this Article: Mark Berneburg, Martin Röcken and Frauke Benedix , 'Phototherapy with Narrowband vs Broadband UVB', Acta Dermato-Venereologica, To link to this article: DOI: 10.1080/00015550510025579 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
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Acta Derm Venereol 2005; 85: 98–108 Phototherapy with Narrowband vs Broadband UVB Mark BERNEBURG, Martin RO ¨ CKEN and Frauke BENEDIX Department of Dermatology, Eberhard Karls University, Tuebingen, Germany Phototherapy with ultraviolet (UV) radiation of wavelengths (v280 nm) is mostly absorbed in the stratum corneum, between 280 and 320 nm (UVB) is a safe and effective UVA (320–400 nm) shows deeper penetration than treatment for a variety of diseases. In addition to standard UVB (280–320 nm) (8–12). Thus, UVB is mainly broadband UVB (bUVB), narrowband phototherapy with absorbed by epidermal components including keratino- fluorescent bulbs emitting near monochromatic UV around cytes, melanin and Langerhans' cells (13). Biological 311 nm (nUVB) has become an important treatment for effects of UV radiation are generated through interac- diseases such as psoriasis, atopic dermatitis and vitiligo. In tion with absorbing molecules called chromophores. In addition to these indications, the number of diseases for which the case of UVB, the most important chromophores nUVB phototherapy is reported to be effective is continuously are proteins such as keratin, melanin, collagen and growing. The differential effects of nUVB phototherapy in elastin, urocanic acid and DNA (14–16). Ultimately, comparison to other UV wavelengths as well as established the interaction of UV with chromophores can lead to a Downloaded At: 13:49 15 May 2007 and new indications for this treatment modality are reviewed.
multitude of effects such as induction of oxidative Key words: broadband UVB; narrowband UVB; phototherapy; stress and activation of transcription factors, as well as psoriasis; skin cancer; ultraviolet light.
induction of damage to the cell membrane and DNA (Accepted October 4, 2004.) Acta Derm Venereol 2005; 85: 98–108.
Induction of DNA damage Dr Mark Berneburg, Department of Dermatology, Eberhard UVB radiation leads directly to the generation of pre- Karls University, Liebermeisterstrasse 25, DE-72076 Tuebingen, mutagenic lesions, so-called photoproducts. Among others, the most prevalent photoproducts induced byUV are cyclobutane pyrimidine dimers (CPD), pyrimidin- While it has been known for more than 2000 years that (6-4)-photoproducts (6-4PP) and Dewar isomers. Normally several skin diseases improve upon exposure to the sun these lesions are repaired by a highly conserved repair (heliotherapy), the systematic investigation of photo- mechanism called nucleotide excision repair (NER).
therapeutic modalities did not start until the beginning This mechanism acts in a tightly regulated fashion of the twentieth century. In 1903, Niels Finsen received including recognition and processing of DNA damage, the Nobel Prize for developing phototherapy as a unwinding of DNA by helicases, excision of the treatment for tuberculosis of the skin and 23 years later Goeckerman (1) showed the beneficial effect of natural DNA polymerase (17). If UVB-induced lesions are sunlight in combination with tar for psoriasis vulgaris. In not repaired, CRT and CCRTT transitions can occur 1953, Ingram (2) initiated the combination of UVB as DNA mutations (18) representing initial events of radiation, dithranol and tar-bathing for psoriasis (2).
multi-step carcinogenesis. These mutations are char- Data from Fischer & Alsins (3) and Parrish & Jaenicke (4) acteristic for UV exposure in potentially relevant genes subsequently showed that wavelengths around 311 nm such as tumour suppressor genes or oncogenes (19).
provoke fewest erythema while being most effective for The fact that defective NER in the autosomal recessive clearing psoriasis. According to these results a fluorescent disease xeroderma pigmentosum is associated with a bulb was developed (TL-01), emitting a major peak at 311 strong increase of DNA mutations, photosensitivity (¡ 2 nm) and a minor peak at 305 nm. This treatment and development of skin cancer further underscores the was later called narrowband UVB (nUVB) and following central role of DNA damage and its repair in the its introduction several studies were published on its process of multi-step photocarcinogenesis (20, 21).
superior efficacy in phototherapy of psoriasis (5–7).
UV radiation and its effects on the immune system UV radiation alters immunological function (22) andUVB can increase the production of pro-inflammatory Interaction between UV radiation and the skin UV radiation that reaches the skin is either reflected necrosis factor (TNF), as well as the production of or absorbed by structures of the skin. While UVC Acta Derm Venereol 85 # 2005 Taylor & Francis. ISSN 0001-5555 Phototherapy with narrowband UVB a-melanocyte stimulating hormone (MSH) and PGE2.
The most important indications will be discussed in UVB down-regulates the expression of intercellular detail below.
adhesion molecule (ICAM)-1 (13). With regard towavelength, reduction of the density and function of Langerhans' cells in the skin and their migration to thedraining lymph nodes is more pronounced with bUVB Monotherapy with nUVB. According to Feldman et al.
than with nUVB (23). Infiltrating epidermal T cells as (39), with regard to efficacy, safety and cost-effectiveness, well as mast cells are susceptible to UVB-induced UVB phototherapy appears to be the best first-line apoptosis (24–26) and depletion of T lymphocytes from treatment for the control of generalized psoriasis and psoriatic lesions seems to be greater after nUVB than there is a large body of evidence indicating that nUVB after bUVB irradiation (27). Moreover, nUVB appears is more effective than bUVB as a monotherapeutic to have a more immunosuppressive effect than bUVB agent in the treatment of psoriasis even in children (5, on natural killer cell activity, cytokine responses and 40–42). Whereas bUVB is considered to be most effec- of peripheral blood tive close to the minimal erythema dose (MED), nUVB mononuclear cells (23, 28) and photo-isomerization of trans- to cis-urocanic acid is more effective with nUVB erythemogenic doses (27). However, Diffey (43) could than with bUVB (23), with urocanic acid photoconver- show in a mathematical model that clearance of pso- sion being mainly induced by wavelengths between 310 riasis plaques is achieved faster with higher MED rates.
and 340 nm (29). Therefore, the immunomodulatory Furthermore, nUVB has been shown to be more Downloaded At: 13:49 15 May 2007 effects of nUVB appear to be more pronounced than effective than bath-PUVA with trimethoxsalen (41, 44), and according to some studies it was as effective as nUVB suppresses the production of interferon (INF)- systemic PUVA therapy (45–47), although this evalua- c, IL-2 and IL-12 and increases that of IL-4 and IL-10, tion was dependent on the type of psoriasis. In a study which together could account for a shift of the immune by van Weelden et al. (46), the therapeutic result differeddepending on the treated body site, with lesions on the trunk responding better to nUVB and lesions on the responses (30–32). The shift from an IFN-c-dominated extremities responding better to PUVA. Other studies Th1 to an IL-4 dominated Th2 response appears to be showed that PUVA is more effective for psoriasis than one of the major factors determining the therapeutic nUVB alone (48) and systemic PUVA remains an efficacy of nUVB phototherapy as well as that of many important therapeutic modality for patients with high systemic treatments such as IL-4 (33), not altering PASI scores, especially those who do not respond plasma antibody concentrations (34).
adequately to nUVB.
In the case of psoriasis, nUVB seems to clear plaques For treatment of psoriasis with nUVB, three rather through local rather than systemic effects, as unexposed than two or five radiations a week are effective (49, 50) plaques cleared significantly less than directly exposed and low incremental regimens are sufficient according plaques (35). However, it has also been hypothesized to Wainwright et al. (51), who showed this regimen to that clearing of psoriasis is a combination of local and be as effective as high incremental regimens but less systemic effects (36).
Combination therapies for psoriasis. In order to reduce INDICATIONS FOR NARROWBAND UVB cumulative UV doses and to enhance clearance of Phototherapy with bUVB or nUVB has been reported psoriasis lesions, combination therapies with topical as to be effective and safe for the treatment of a large well as systemic agents have been established: number of skin diseases. In addition to psoriasis, atopic nUVB plus dithranol (Ingram): In many studies the dermatitis (AD) and vitiligo, various other skin diseases efficacy of dithranol combined with UVB (broadband can be treated successfully with nUVB phototherapy, or narrowband) could be shown (7, 52, 53). As dithranol like parapsoriasis, initial mycosis fungoides (MF), graft- is difficult to handle, this therapy is mainly reserved for versus-host disease and pruritus, as well as acquired hospital settings.
perforating dermatosis, lichen planus, lichen simplexchronicus, lymphomatoid papulosis, generalized granu- UVB plus vitamin D3 analogues: Vitamin D3 analogues loma anulare, nummular dermatitis, pityriasis liche- inhibit proliferation, induce terminal differentiation of noides chronica, pityriasis rosea, pityriasis rubra pilaris, human keratinocytes and exhibit immunomodulating pruritic folliculitis of pregnancy, seborrhoeic dermatitis, properties (54). Several studies showed that calcipotriol Schnitzler's syndrome and Sneddon-Wilkinson disease as well as calcitriol and tacalcitol are efficacious, safe (as reviewed in refs 37, 38). Table I depicts newer and can be used on a long-term basis for psoriasis (55– studies reporting efficacy and possible combinations of 58). Vitamin D3 analogues, when used after nUVB nUVB phototherapy with other treatment modalities.
Acta Derm Venereol 85 M. Berneburg et al.
Table I. Recent studies (published since 1999) involving narrowband UVB (nUVB) shown with regard to patient number (n), studydesign and response rate (in some cases descriptive values in results have been calculated from the studies original data to facilitatecomparison between studies) PsoriasisPasic (42) >90% PASI reduction: 45% 84% (PUVA), 63% (nUVB);6 month remission: 35% (PUVA),12% (nUVB) PASI reduction: 84% (nUVB); 89% non-randomized (25) Half-side, randomized, 100% (nUVB), 70% (bath-PUVA) observer-blinded (10) Half-side, randomized PASI reduction: 77% (nUVB); 45% Open, randomized, Treatments to clear: 25; days to clear: 67 (nUVB), 66 (PUVA) Half-side, open (12) PASI reduction: 67.8% (nUVB), Multicentre (280) 71.4% improvement Downloaded At: 13:49 15 May 2007 PASI reduction: 83.9 ¡ 15.6% Prospective, randomized, Significant higher PASI reduction with calcipotriol w95% response: 90.0% (withcalcipotriol), 61.1% (no calcipotriol) Half-side, controlled (10) CR: 100% both groups PASI only on arms Half-side, open (10) PASI reduction 48% (nUVB):64% (nUVB/tazarotene), CR: after 19 treatments on w50% response: 38% (tacalcitol) After 6 weeks equal 86% (tacalcitol/nUVB), Retrospective (40) w75% response: 72.5% Recalcitrant psoriasis Atopic dermatitisPasic (42) >90% SCORAD reduction: 45.4%; 70–90% reduction: 22.7% Response: 81%; CR: 43%, (87)Reynolds (89) Randomized, controlled Reduction of activity: 83% (nUVB), 47% (UVA),47% (Visible light) Pruritus reduction: significant Half-side, open (9) Reduction of Costa and Leister score:40% and 50% (nUVB), 33% and30% (UVA1); pruritus: 67% (nUVB),34% (UVA1) Half-side, randomized, SCORAD reduction: 65.7% (bath-PUVA), 64.1% (nUVB) SCORAD: 63.3% (CsA); relapses treated with nUVB led tofurther SCORAD-reduction (total59.9%) Mycosis fungoides (MF) and parapsoriasisGathers (93) Retrospective (24) CR: 54.2%; PR: 29.2%; 30% of CR relapse after 12.5 weeks CR: 75%; relapse after 20 months CR: 95%; relapses: 100% within a SPP and early-stage MF Retrospective (56) CR: 81% (nUVB), 71% (PUVA); remission in months: 24.5 (nUVB),22.8 (PUVA) Acta Derm Venereol 85 Phototherapy with narrowband UVB Table I. (Continued.) VitiligoScherschun (99) Retrospective (7) 75% response: 71.4%; rest: Response depended on 50–40% response 75% response: 53%; stable disease: Children; localization (100% repigmentation: 92%; equal response with FA and vitamin B12 PruritusBaldo (107) Polymorphous light eruptionDummer (113) Response: 80% (nUVB), 66.6% nUVB effective after ineffective UVA/UVB Retrospective (5) Spontaneous clearing: CR: 70%; significant improvement: Pityriasis lichenoidesPasic (42) >90% reduction: 33.3%; 70–90% Downloaded At: 13:49 15 May 2007 Lichen planusSaricaoglu (123) CR: 100% (30–51 radiations) CR: 100%; Remission: >5–21 months Oral lesions: noresponse Seborrhoeic dermatitisPirkhammer (124) CR: 33.3%, PR: 66.6%; pruritus: 100% All relapsed after 21 d CR, complete remission; PR, partial remission; MF, mycosis fungoides; SPP, small plaque parapsoriasis; SCORAD, Severity Scoring of AtopicDermatitis; PUVA, psoralen with UVA; PASI, Psoriasis Area and Severity Index.
Furthermore, clearing of plaques occurs faster if vitamin nUVB (73, 74). A multicentre study with 280 psoriasis D is applied (59–61). Vitamin D3 derivatives may be patients describes a PASI reduction of 71.4% when used up to 2 h before phototherapy (62, 63) or after UV patients are irradiated with nUVB in the presence of application, as they are unstable under UV irradiation Dead Sea salt solution (75). These are encouraging data, (64). One study showed that pretreatment with tacalcitol but controlled comparative trials are needed to support accelerated the response to nUVB (65).
these results.
Hofmann et al. (66) found no difference in the efficacy Combination of UVB and systemic therapy: UVB plus of the combination of nUVB with dithranol versus systemic retinoids (isotretinoin and acitretin) can nUVB with calcipotriol in a half-side trial. However, improve the efficacy of nUVB, almost reaching the studies with higher patient numbers are necessary to effectiveness of PUVA (76). In patients refractory to confirm this finding.
other treatments, the combination of low-dose acitretin UVB plus topical retinoids: In clinical studies, tazarotene and nUVB results in greater improvement than mono- 0.1% gel in combination with nUVB showed faster and therapy with either acitretin or nUVB (77) and retinoids significantly greater reduction of psoriasis plaques with may protect against development of squamous skin significantly lower median cumulative UV exposure cancer (78–81). Thus, combination of nUVB with than UVB alone (67, 68). Mild irritations like erythema, systemic retinoids is a possible alternative to avoid large peeling, dryness, burning and pruritus do occur but cumulative PUVA doses.
photosensitivity is not observed (69, 70). Comparison of UVB plus psoralen: Psoralen is normally combined with tazarotene plus nUVB versus calcipotriol plus nUVB in UVA (PUVA). Anecdotal reports describe equal effi- clinical studies revealed no significant therapeutic cacy of psoralens in combination with nUVB when difference (71). However, reduction of stratum corneum compared to PUVA, although it is unclear to what by retinoids increases UV erythemogenicity and a more extent improvement was due to nUVB radiation alone cautious increment of UV is recommended when (82–84). The combination of bath-PUVA plus addi- combined with tazarotene (72).
tional nUVB has also been described with nUVB UVB plus salt: Balneophototherapy is a widely applied enhancing the phototoxic and therapeutic activities of treatment modality in combination with bUVB or bath-PUVA (85).
Acta Derm Venereol 85 M. Berneburg et al.
Atopic dermatitis now there has been no clinical evidence suggesting thatUVB treatment promotes progression of MF.
There is a large body of evidence indicating that nUVBis effective in the treatment of atopic dermatitis (86). In a recent study, Pasic et al. (42) combined nUVB withUVA for AD in children and showed >90% reduction No randomized controlled trials investigating the efficacy of the SCORAD index in 45.4% and 70–90% reduction of nUVB in the treatment of vitiligo have been published in another 22.7% of patients. Hudson-Peacock et al. (87) so far. However, several clinical studies report that nUVB described a response rate of 81% with complete can achieve up to w75% repigmentation in about two- clearance in 43% for nUVB twice weekly. The first thirds of patients after at least 1 year of treatment (98, randomized investigator-blinded, half-side comparison 99). Repigmentation w90% can even be observed (100).
study on the efficacy of 8-methoxypsoralen bath-PUVA nUVB seems to be more effective than bUVB, local versus nUVB in patients with severe chronic AD found steroids or PUVA (101) and this wavelength also appears equal effectiveness after a mean duration of 40 days to be effective in children (102). Body areas with good when used three times a week in equi-erythemogenic responses (w75%) include face, neck, trunk and proximal doses (88). Another randomized, controlled, double- extremities, whereas distal extremities as well as genital blind study with 73 patients treated with nUVB, bUVB/ areas respond very modestly (v25%) or not at all. nUVB UVA or visible light twice a week showed nUVB to be seems to be safe as regards photocarcinogenicity, as up to most effective with respect to the following end points: now only two patients with vitiligo have been reported to disease activity and ability to sleep for up to 3 months develop squamous cell carcinoma after prolonged PUVA Downloaded At: 13:49 15 May 2007 after cessation of therapy (89). Furthermore, nUVB therapy (103, 104).
was shown to be as effective as medium-dose UVA1in clearing chronic AD and better in reducing pruritus Combination of nUVB phototherapy with cyclo- Phototherapy of pruritus can be effective due to treatment sporin A (CsA) has been reported to be effective in the of the underlying disease, such as AD, lichen planus or treatment of AD. Patients with severe AD were treated lymphoma. Symptomatic improvement can also be with oral short-term CsA for 4 weeks. Then CsA was achieved by phototherapy in pruritus associated with washed out for 4–6 weeks followed by nUVB photo- uraemia, primary biliary cirrhosis, macular amyloidosis therapy applied three times a week for up to 2 months.
and Hodgkin's lymphoma (105). According to Hsu & This regimen showed good clinical response. However, Yang (106) uraemic pruritus responds only to bUVB but the study did not investigate long-term effects of this not to nUVB. Baldo et al. (107) showed nUVB to be protocol (91) and this combination has to be viewed effective for treatment of pruritus associated with poly- cythaemia vera. One open trial study showed that thecombination of initial thalidomide followed by nUVB for Early stage mycosis fungoides and parapsoriasis en prurigo nodularis leads to an excellent response after an average of 12 weeks (108).
Several studies indicate the beneficial effect of nUVB for Polymorphous light eruption patch-stage MF (Ia/Ib) and parapsoriasis (92, 93). Timesto reach complete remissions range from 6 weeks (92) up Polymorphous light eruption (PLE) is mainly provoked to 66 months (94). The time to relapse after complete by UVA and to a lesser extent by a combination of responses after photochemotherapy with PUVA ranges UVA/UVB or UVB alone and a light-hardening effect between 6 and 43 months (95). For nUVB prolonged can be seen. For patients with severe forms of PLE remission up to 20 months has been described (96).
effective photo-hardening in spring with nUVB has been Diederen et al. (94) describes even higher complete described as equally effective as with PUVA, UVA1 or remissions rates and longer mean relapse-free intervals bUVB (109, 110). Photohardening with nUVB has also when comparing nUVB with PUVA (81% vs 71% resp.
been used for actinic prurigo, idiopathic solar urticaria, 24.5 vs 22.8 months). Some authors propose a main- tenance phototherapy once a week after complete sensitivity, congenital erythropoietic protoporphyria, clearing of MF. As p53 mutations were described in homozygous variegate porphyria or hydroa vacciniforme, tumour stage MF with a mutation spectrum strikingly even when patients showed abnormal photosensitivity in similar to that reported in non-melanoma skin cancer the UVB spectrum (86, 111, 112). PLE lesions provoked and characteristic for DNA damage caused by UVB by UVA and UVB may respond to photohardening with radiation, precautions regarding long-term photother- nUVB, even in patients where UVA/UVB treatment was apy have to be taken (97). Even though treatment of MF inefficient. On the other hand, if PLE lesions are induced with UVB still raises the issue of carcinogenicity, until by bUVB, correct application of nUVB might be Acta Derm Venereol 85 Phototherapy with narrowband UVB impossible. In these very rare cases PUVA therapy has Late side effects been reported to be a valid alternative (113).
Chronic exposure to UV radiation induces prematureaging (photoaging) of the skin, showing typical clinical signs of leathery appearance, wrinkling, reduced recoil The first-line treatment for graft-versus-host disease capacity and increased fragility of the skin (128, 129).
(GvHD) is photochemotherapy (PUVA), especially Both wavelengths UVA and UVB are capable of when the skin involvement is severe. Moreover, inducing the different metabolic changes that result in Grundmann-Kollmann et al. (114) reported 10 patients, enhanced skin aging (128, 130). The relative influence of resistant to combinations of immunosuppressive drugs, nUVB in comparison to UVA or bUVB has not yet been of which seven patients showed complete clearance after treatment with nUVB five times a week over 3–5 weeks.
More important than photoaging after chronic UVB After clearing of cutaneous GvHD, radiation was exposure is the risk of skin tumour induction. While the continued as maintenance therapy for at least 4 weeks role of PUVA in the induction of skin tumours is and no patient relapsed during a follow-up of 4–18 undisputed, in humans the role of UVB phototherapy in months. As nUVB phototherapy is a non-aggressive skin carcinogenesis is less clear. No significant increase treatment that may be of benefit for patients who in the risk of developing squamous cell carcinoma or are receiving higher doses of immunosuppressive basal cell carcinoma has been associated with long- drugs, including CsA or FK506, this form of photo- term exposure of patients with psoriasis to bUVB therapy may be an alternative to systemic and topical phototherapy in older and recent studies (131–133), Downloaded At: 13:49 15 May 2007 PUVA in mild cases or during onset of the disease even in combination with crude coal tar over 25 years (134). At present it is not clear whether nUVB or bUVBis more carcinogenic. Several animal studies found Rare diseases and other indications that nUVB has a higher carcinogenic potency thanbUVB (135–137), while others did not confirm this There are anecdotal reports of using nUVB in various (4, 5, 138–140). Macve & Norval (141) showed that other diseases. Thus nUVB has been successfully used tumour outgrowth is enhanced by bUVB, but not for subcorneal pustular dermatosis (Sneddon-Wilkinson by nUVB or UVA1. Remarkably, cis-urocanic acid disease) (116, 117), acquired perforating dermatosis seemed not to be important for tumour induction, (118) and pruritic folliculitis of pregnancy (119).
although it is recognized as an initiator of UV-induced For classical juvenile pityriasis rubra pilaris (PRP), a good clinical result was observed with nUVB in Throughout the UVB spectrum, the first DNA lesions combination with acitretin (120). Notably, PRP can be induced are pyrimidine dimers, but the number of provoked by UV irradiation and painful and tense dimers produced decreases dramatically with longer UV lesional blistering has been described under nUVB.
wavelengths. For example, irradiation of human fibro- Thus, phototesting prior to initiation of nUVB as well as blasts with equal UVB energy produces 100 pyrimidine discrete dose increments are mandatory (121). Patients dimers at 302 nm, but only 1 dimer at 312 nm.
with lichen planus have successfully been treated with Similarly, 60 functional mutations of the hypoxanthine nUVB: pruritus responded early and a complete flattening occurred within 30–51 radiations and no 302 nm, but only one is produced at 312 nm (142).
relapse was seen during follow-up of 20 months. Again, These data were confirmed by Tzung & Runger (143) photoaggravated lichen planus should be kept in mind and Budiyanto et al. (144), who showed 10-fold higher doses of nUVB yielding a similar amount of CPD and Other diseases responding to treatment with nUVB also a 1.5–3 times higher amount of oxidative DNA include chronic pityriasis lichenoides in children, but not damage compared with bUVB.
pityriasis lichenoides et varioliformis acuta (42) and Data investigating the carcinogenic risks of nUVB seborrhoeic dermatitis (124).
and bUVB are limited. When used in humans nUVBseems not to be associated with a higher carcinogenic ADVERSE EFFECTS OF NUVB risk when compared with bUVB, but a significantlyreduced risk compared with PUVA (145, 146). A first Early side effects long-term retrospective study by Weischer et al. (147) Early side effects of nUVB include erythema and during a follow-up of 10 years further supports the view dryness of the skin. The maximum erythema occurs that neither nUVB nor bUVB significantly increase the 8–24 h after irradiation (125, 126). As patients over 70 risk of skin cancer. Nevertheless, phototherapy must be years show a prolonged nUVB-induced erythema, a applied with due caution and patients possibly receiving more cautious approach to dose increases is recom- long-term phototherapy should be followed-up by a mended in the elderly (127).
dermatologist on a regular basis.
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