Contributed by Kimberly Bohjanen, MD, Director of Phototherapy
For cutaneous T cell lymphoma (CTCL) that progresses to thick tumors, treatment with UVA phototherapy and the medication psoralen (PUVA) is common. As is the case for most chronic skin conditions that improve with phototherapy, treatment sessions are indicated to occur several times a week. Treatment frequency and expense, however, can affect patient compliance. Oral psoralen (Oxoralen-Ultra), since its approval by the FDA as a skin cancer treatment, has quintupled in price over the last six years.1 Here we describe the case of a referred patient with CTCL who, concerned with the cost burden of therapy, successfully transitioned to a new treatment option UVA-1 phototherapy.2
A middle-aged female with tumorstage CTCL was referred by her dermatologist at the Mayo Clinic in Rochester, MN, for PUVA treatment at University of Minnesota Health Dermatology Clinic. The patient had received PUVA 3 times per week for more than 12 months to treat thick cutaneous tumors. During this time, the patient indicated that her medication, oral Oxoralen-Ultra, had become too expensive for her to afford. Although the patient had responded well to PUVA, she required continued treatment. Given that phototherapy sessions were indicated for multiple times per week, the patient was in need of more affordable phototherapy located a reasonable distance from her residence.
Reviewing the patient’s case and her concerns about treatment cost, M Health dermatologists proposed treatment with whole-body UVA-1 and explained that this phototherapy did not require use of photosensitizing medication. The patient agreed to the alternate therapy. She was taken off of PUVA phototherapy and transitioned to UVA-1 phototherapy sessions at mid-range exposure (50 mJ/cm2) 3 times a week. She responded well to UVA-1 treatment and no longer suffers from photosensitization and nausea as she had with PUVA treatment. Monthly evaluations have indicated that tumor inflammation and thickness are well managed. The care team has incorporated a plan for weaning the patient from UVA-1 treatments upon clinical remission of CTCL.
Medication cost and treatment frequency often affect patient compliance to therapy. UVA-1 phototherapy can address these factors; however, it is not an alternative for every dermatology patient who has benefited from PUVA. In patients with CTCL, evidence for UVA-1 efficacy has been reported.2 Nevertheless, additional factors such as tumor thickness and prior response to PUVA should be reviewed before physicians consider the safety and efficacy of transitioning a patient with CTCL from PUVA to UVA-1. For this patient, tumor thickness, treatment side effects, and medication costs were all essential factors in the care team’s determination that UVA-1 phototherapy was the best alternative course of treatment.
The new high-intensity form of phototherapy can reach the inflammatory cells that drive many chronic skin conditions without requiring patients to take photosensitizing medications.Continue reading