Phototherapy in ChildrenPhototherapy in Children

Kathryn ThomsonKathryn Thomson

Why are Children Different?Why are Children Different?

Not just small adultsNot just small adults– heightheight– Body Surface Area:mass ratioBody Surface Area:mass ratio– psychological differences: understanding, anxiety, psychological differences: understanding, anxiety,

compliance, needs, peer response, stigmacompliance, needs, peer response, stigma– long term impact- longer potential “treatment life”long term impact- longer potential “treatment life”– extra people involved: parents/ carersextra people involved: parents/ carers– response to treatmentresponse to treatment– smaller treatment numbers therefore data not so smaller treatment numbers therefore data not so

availableavailable– data needs to be treated with caution as children data needs to be treated with caution as children

often more severe than adults before phototherapy is often more severe than adults before phototherapy is consideredconsidered

• review of the literaturereview of the literatureefficacy of phototherapy in different conditionsefficacy of phototherapy in different conditions

risksrisks

published experience from different unitspublished experience from different units

• ideal requirementsideal requirements• tips on managing phototherapy in childrentips on managing phototherapy in children

Phototherapy for children with Phototherapy for children with PsoriasisPsoriasis

psoriasis estimated at affecting 0.75% psoriasis estimated at affecting 0.75% population under 18 yearspopulation under 18 years

significant impact on quality of lifesignificant impact on quality of life

most studies look at NB-UVB with a few most studies look at NB-UVB with a few looking at PUVA and BB-UVBlooking at PUVA and BB-UVB

Psoriasis StudiesPsoriasis Studies

Parlovsky et al JEADV 2011Parlovsky et al JEADV 2011– 88 patients; mean age 12 years (8-16)88 patients; mean age 12 years (8-16)– 92% improved >75% or cleared92% improved >75% or cleared– BUT treatment course 3.1 +/- 2.3 monthsBUT treatment course 3.1 +/- 2.3 months

Ersoy-Evan et al -Paediatric Dermatology 2008Ersoy-Evan et al -Paediatric Dermatology 2008– 28 patients; mean age 12years+/- 2.528 patients; mean age 12years+/- 2.5– 92.9% clear or minimal residual disease (mrd) 92.9% clear or minimal residual disease (mrd) – mean treatment number= 16 for guttate, 36 for large plaquemean treatment number= 16 for guttate, 36 for large plaque

Tan et al- Australas J Dermatology 2010Tan et al- Australas J Dermatology 2010– 38 patients; mean age 11 (2.6-15.9)years38 patients; mean age 11 (2.6-15.9)years– mean treatment number 27.8 (range 4-76)mean treatment number 27.8 (range 4-76)– 90% patients reach >75% reduction or clear90% patients reach >75% reduction or clear

Atopic EczemaAtopic EczemaLeeds study 2009Leeds study 2009– retrospective database review over 6 yearsretrospective database review over 6 years– 50 children with eczema had 10 or more treatments50 children with eczema had 10 or more treatments– clear or mrd in 40%, good imp in 23%, mod imp in 26%clear or mrd in 40%, good imp in 23%, mod imp in 26%– children with higher MED more likely to clearchildren with higher MED more likely to clear

Darne et al BJD 2014 (Newcastle) Darne et al BJD 2014 (Newcastle) – prospective studyprospective study– SASSAD/ percentage involvement/ QoL scores comparing 29 SASSAD/ percentage involvement/ QoL scores comparing 29

children (age 3-16) with 26 controls (suitable for treatment but children (age 3-16) with 26 controls (suitable for treatment but opted out)opted out)

– 61% cw 6% reduction in SASSAD61% cw 6% reduction in SASSAD– 11% cw 36% percentage area11% cw 36% percentage area– significant reduction in QoL scoressignificant reduction in QoL scores– maintained at 6 monthsmaintained at 6 months

eczema (continued)eczema (continued)

Glasgow group Jury et al CED 2006Glasgow group Jury et al CED 2006– median treatments 24 (range 3-46)median treatments 24 (range 3-46)– 68% achieved mrd, 16% no better68% achieved mrd, 16% no better

cautions in eczema patients;cautions in eczema patients;

increased risk of cataracts (consider increased risk of cataracts (consider ophthalmology review)ophthalmology review)

reactivation of herpes simplexreactivation of herpes simplex

VitiligoVitiligo

Ersoy-Evans et al 2008Ersoy-Evans et al 2008– 26 patients26 patients– 9 treated with TLO1, 8 with PUVA, 9 with 9 treated with TLO1, 8 with PUVA, 9 with

topical meladinine and UVAtopical meladinine and UVA– 57% patient achieved 50% repigmentation 57% patient achieved 50% repigmentation

with PUVA; 50% with TLO1with PUVA; 50% with TLO1– only 2 of 9 with maladinineonly 2 of 9 with maladinine– median treatment number= 24.5 (range 17-median treatment number= 24.5 (range 17-

106) for PUVA and 14 (9-107) for TLO1106) for PUVA and 14 (9-107) for TLO1

Vitiligo (continued)Vitiligo (continued)

Grimes et al Paediatric Dermatology 1986Grimes et al Paediatric Dermatology 1986– children seem to have a better response to PUVA children seem to have a better response to PUVA

than adultsthan adults

response probably variableresponse probably variablePercivalle et al Paed Derm 2012Percivalle et al Paed Derm 2012– TLO1 in 28 children twice weekly (duration 10+/-3.4 TLO1 in 28 children twice weekly (duration 10+/-3.4

monthsmonths– 14% excellent response, 28.6% good response, 25% 14% excellent response, 28.6% good response, 25%

moderate response, 28.6 mildmoderate response, 28.6 mild– 3.5% no response3.5% no response– no side effects other than erythemano side effects other than erythema– recommend stopping at 6 months if no betterrecommend stopping at 6 months if no better

Photodermatoses including PLEPhotodermatoses including PLE

large patient series report good levels of large patient series report good levels of protection with UVA, UVB and PUVAprotection with UVA, UVB and PUVA

NBUVB probably treatment of choice as NBUVB probably treatment of choice as has shown in adults to be as effective as has shown in adults to be as effective as PUVAPUVA

Why use Phototherapy?Why use Phototherapy?

Some children do not get adequate response from Some children do not get adequate response from topical treatmentstopical treatmentsactive skin disease has large effect on daily life of active skin disease has large effect on daily life of children and familieschildren and familiesPhototherapy often preferable to oral Phototherapy often preferable to oral immunosuppressantsimmunosuppressantsData suggests that it is a useful treatment Data suggests that it is a useful treatment

BUTBUTLong term potential side effects still uncertain to treat Long term potential side effects still uncertain to treat with caution with caution requires commitment from patient and families requires commitment from patient and families

What Do we need to consider when What Do we need to consider when treating Children? treating Children?

Social aspectsSocial aspects– phototherapy course may take a number of phototherapy course may take a number of

weeksweeks– patient may need time off schoolpatient may need time off school– parent/ carer may need time off workparent/ carer may need time off work– treatment may need to be explained to the treatment may need to be explained to the

school school

Patient AnxietyPatient Anxiety

phototherapy machines can be scary for childrenphototherapy machines can be scary for childrenthey may feel hot and airlessthey may feel hot and airless

careful explanation to parent and childcareful explanation to parent and childclear child friendly information sheetsclear child friendly information sheetsearly introduction to machine and staffearly introduction to machine and staffallow extra time at assessment clinicallow extra time at assessment clinicallow to stand in machine with door open and allow to stand in machine with door open and

clothes on clothes on before treatment startsbefore treatment startsallow to try on the goggles and make it funallow to try on the goggles and make it funtreatment can be split if longer sessiontreatment can be split if longer sessionif needed parent can go in machine (covered up)if needed parent can go in machine (covered up)consider audio tapes for longer sessionsconsider audio tapes for longer sessions

Parental CounsellingParental Counselling

explain how machine worksexplain how machine worksexplain need for goggles/ visorexplain need for goggles/ visorreduce ambient sun exposure (sun screen/ hats, avoid reduce ambient sun exposure (sun screen/ hats, avoid hottest part of the day etc)hottest part of the day etc)

Include child in all decision making. If possible get both Include child in all decision making. If possible get both child and parent to sign the consent formchild and parent to sign the consent formUse reward (star) cards/ stickers/ certificate on Use reward (star) cards/ stickers/ certificate on completion (age appropriate)completion (age appropriate)

Practical ConsiderationsPractical Considerations

Tubes get weaker towards the bottom. As young children Tubes get weaker towards the bottom. As young children are smaller they should stand on a platform for treatmentare smaller they should stand on a platform for treatmentAs for most paediatric patients ensure a child As for most paediatric patients ensure a child appropriate waiting area- books, toys etcappropriate waiting area- books, toys etcIf possible a nurse with paediatric experience should be If possible a nurse with paediatric experience should be availableavailable Children get bored quickly – try to be on time and get Children get bored quickly – try to be on time and get parents to bring things to entertain themparents to bring things to entertain themIf using PUVA, oral not ideal as children less likely to be If using PUVA, oral not ideal as children less likely to be compliant with glasses and parents wont always be with compliant with glasses and parents wont always be with them.them.If goggles needed allow patient to choose themIf goggles needed allow patient to choose them

SummarySummary

All types of phototherapy have been All types of phototherapy have been shown to be effective in children.shown to be effective in children.

If planned well anxieties can be managed If planned well anxieties can be managed and may enable the avoidance of oral and may enable the avoidance of oral immunosuppressantsimmunosuppressants