Comparing Home and Office-Based UVB Phototherapy: Insights from the LITE Study

Announcer:
You’re listening to On the Frontlines of Psoriasis on ReachMD. And now, here’s your host, Dr. Charles Turck.

Dr. Turck:
This is On the Frontlines of Psoriasis, on Reach MD. I’m Dr. Charles Turck. And joining me to discuss his recent study comparing home and office-based narrowband UVB phototherapy for patients with psoriasis is Dr. Joel Gelfand. Dr. Gelfand is a dermatologist and the Director of both the Psoriasis and Phototherapy Treatment Center and the Center for Clinical Sciences in Dermatology at the University of Pennsylvania. Also joining us is Valerie Harrison, a patient who participated in the study and a member of the National Psoriasis Foundation’s Board of Directors.

Dr. Gelfand, Valerie, welcome to the program. 

Dr. Gelfand:
It’s great to be here. 

Ms. Harrison:
Great. Thank you for having me. 

Dr. Turck:
Well, starting with you, Dr. Gelfand, would you give us some background on the study and why you decided to compare home and office-based phototherapy? 

Dr. Gelfand:
This is a very unique study that we did in the field of dermatology and even in medicine in general. It was really a patient-centered, patient-driven research study that we did. We were involved in doing some research in clinical practices across the United States to understand how therapies were working in real-world settings for patients with psoriasis, and we did a lot of surveys of patients affected by psoriasis and clinicians who treat patients with psoriasis. And what we learned from this work was that, despite all the advances we made in new oral medications and biologics for psoriasis, patients still really value phototherapy. And they really wanted to understand how well phototherapy worked at home compared to the office as a way of making that treatment more centered on the patient’s life as opposed to the dermatologist’s life and practice. When we did the same surveys of dermatologists, they actually felt phototherapy was a great treatment and that it was a perfect first-line option for many patients, but they weren’t interested in studies of home phototherapy. They want to focus on biologics.

And so there’s something called the Patient-Centered Outcome Research Institute, PCORI, and they fund research that’s really patient-driven and that answers questions that are important to patients and other stakeholders in a way that will change clinical practice to make it more patient-centered. And that was really what we were trying to understand in the study: could we deliver the same quality of care with a home phototherapy machine delivered to the patient’s house as we could in the office? And if we could, that would have tremendous advantages, because one, we dermatologists were not well geographically distributed, so for many patients across the United States, they may not even be able to access a dermatologist’s office that has phototherapy. And then, in a modern era, very few people have the ability to get to a doctor’s office three times a week. Even though treatments are quick, that burden of getting off from work to do this and getting back to work, it’s just very disruptive of patients’ lives, and so we felt this was really a patient-centered question to answer. Patients were involved in all aspects of the study; they helped us design it, helped us choose the outcomes we were looking at, and ultimately oversaw the study with us. Some were authors in the paper, and the study was funded by PCORI.

Dr. Turck:
And looking at the results, what did you discover about these two forms of treatment?

Dr. Gelfand:
The results really exceeded our expectations. First of all, from a scientific point of view, this is defined as a noninferiority trial. So, statistically speaking, we would say home phototherapy worked as well as office phototherapy for both patient-reported outcomes, having minimal to no impact on their health-related quality of life and, to physician outcomes, the skin being clear or almost clear of psoriasis. But in reality, when we look at the data, patients in home phototherapy did much better. They were more likely to achieve clearer skin, more likely to have no impact or minimal impact on health-related quality life than office phototherapy, less likely to have to continue using topical therapies, a strong trend towards being less likely to have to go on to other treatments like biologics, for example, and they were much more adherent. They were three times more likely to be able to get two treatments a week, which is the optimal way of managing psoriasis with phototherapy. And the other thing that was kind of surprising is that for people who were adherent—meaning they did about roughly two treatments a week—those at home and those in the office did just as well, as you would expect, because the machines are offering the same ultraviolet light as in the office. So it’s really the ability to get the treatment that makes a difference. And the clearance rates were very high. Roughly 60 percent of patients were clear or almost clear after 12 weeks of treatment, which does rival some of our better, more modern therapies for psoriasis.

The other thing I should point out is that when we dose ultraviolet light phototherapy, it’s based on the patient’s skin tone, so it’s a lower dose for someone with fair skin, a moderate dose for someone with medium-complected skin, and a higher dose for someone with darker skin, and then the dose is adjusted accordingly as people adapt to the ultraviolet light treatment. And what we found is that whether you were very fair-skinned or had very darkly pigmented skin or somewhere in between, that patients did just as well at home as they did in the office.

Dr. Turck:
Now, turning to you, Valerie, what was it like to participate in this research?

Ms. Harrison:
So I must say—and this is not hyperbole—it was really transformative in many ways. I received office-based phototherapy before, and as Dr. Gelfand mentioned, although I have the luxury of being in a large urban area with a lot of resources—I work 20 minutes from where the photo therapy machine is—the notion of trying to get out of work to get there three times a week, find a parking space, run upstairs to get it, and have that compliance is a real barrier despite your best efforts. Consistency and the lack of consistency impacted the effectiveness of the treatment. And so when I had the opportunity to be in the study, I had a home-based system of treatment, and consistency was no longer an issue. It was no longer a barrier.

Phototherapy is an effective treatment for me. I’m not saying it’s for everyone, but for me, I am African American, so my skin is darker. It works for me. And so there are those physicians who do it best, like Dr. Gelfand, and I think the practice of medicine is often also giving people hope. And so, aside from the outcome being one that was effective for me in terms of the physical piece of it, there’s also a psychological piece to this. Having it there and seeing these kinds of results gives patients an incredible amount of hope

Dr. Turck:
For those just joining us, this is On the Frontlines of Psoriasis on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Joel Gelfand and Valerie Harrison about home and office-based narrowband UVB phototherapy for managing psoriasis.

So, Valerie, staying with you for a moment, what advice would you give to other patients with psoriasis who are considering home or office-based phototherapy? 

Ms. Harrison:
To be persistent and to talk to your physician about the many options that are available. My journey with psoriasis began decades ago, and as a Black person, finding a physician who truly understands the unique challenges of treating Black skin may not always be easy. The manifestations may look different for different people. The treatment options may vary, and what works for one may not work for another. And so the advice that I have is to raise this issue.

I think that phototherapy is a viable option for many of us and I would advocate for patients talking to their physicians about it. And now, with the insurance rules changing somewhat, if you’re not in a location where you can easily get to an office machine, get a prescription for one. Try it in your house. It’s easy. You can set it up in 15 minutes. It’s tall, but it’s not wide, so it doesn’t take up a lot of space in a home, but it is something I think that patients should explore.

Dr. Turck:
Before we end today’s program, I’d like to ask each of you one more question. Starting with you, Dr. Gelfand, how do you see these results impacting clinical practice? 

Dr. Gelfand:
A disease like psoriasis is a chronic condition that people will live with for many years. It’s really important for patients to be empowered and to know about the disease and their treatment options. The National Psoriasis Foundation is a good place to go to for information about the topical and oral medications we use, as well as biologics, phototherapy, dietary approaches, stress management, and all those things that go into helping people make good choices and live healthier lives free of psoriatic disease. A patient with psoriasis where disease is on areas like the arms, legs, trunk, and even the face tends to be a good candidate for phototherapy. If it’s in more hidden areas, like in the in the scalp, fingernails, and genitals, those are areas that ultraviolet light doesn’t work as well.

But in terms of clinical practice, Valerie has talked about how it’s already impacting clinical practice. Home phototherapy has been available for psoriasis for many years, and the challenge we had was a huge variation in insurance companies making it available to patients, and that was often because there wasn’t a lot of large-scale data out there to make insurers feel comfortable with home phototherapy. The LITE study had 783 patients at 42 dermatology practices across the country. No patients stopped home phototherapy due to side effects, significant burns, or anything like that because the machines are now modernized and computer dose controlled. And so it’s pretty difficult to get the wrong dose when you’re doing home treatment with these more modern machines.

But that being said, it’s covered by Medicare. It’s a widely accepted treatment option out there. It’s really just the complexity of the healthcare system and making it available to people. It is much less expensive than the more modern biologics. A home phototherapy machine may cost roughly 5,000 to 6,000 dollars. It’s a one-time fee. There may be some costs over time related to the machine needing calibration or new bulbs years later, and the cost of electricity is minimal. This is compared to, say, a biologic, which may cost 60,000 dollars or more per year per life. Right? So insurers now understand that this, in fact, is a modality they should make available to patients because it works well, it’s safe, and it’s relatively inexpensive. 

Dr. Turck:
And, Valerie, I’ll give you the final word. Is there anything you wish doctors and researchers knew about living with this condition? 

Ms. Harrison:
I think I would say that my doctor understands that hope can be as much a part of the treatment as a topical ointment or a biologic in many, many ways, because the stress of the disease actually can exacerbate the condition. And so when you have a physician or a researcher who takes the time to explain the disease and its nature to a patient so that they have a good, solid understanding, when they actually do the research and they’re interested in the research and make that research available, and then, finally, when they advocate for better care and coverage, those are the things I think that patients wish for. Those are the things that we are most appreciative of. And I’ll say it again over and over, I have the best dermatologist around in the game, and so I have all of these. And I think because of all of these things, I have great hope. I can walk with confidence knowing that there will be continual improvement for me and for other patients like me. 

Dr. Turck:
Well, with those final insights in mind, I want to thank my guests, Dr. Joel Gelfand and Valerie Harrison, for joining me to discuss recent research on how home and office-based narrowband UVB phototherapy compare in treating psoriasis.

Dr. Gelfand, Valerie, it was great having you both on the program. 

Dr. Gelfand:
Great being here.

Ms. Harrison:
Thank you. 

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