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EADV 2020 | Controversies: Phototherapy in Children

Pediatric, Phototherapy 2020

Presented by Dr. Chiara Cortelazzi, MD, and Marina Venturini, MD

A report from the 29th Congress of the European Academy of Dermatology and Venereology


Phototherapy is commonly used in adult psoriasis, but is phototherapy safe and effective in children?

 

YES: Dr. Cortelazzi argued that narrowband UVB (nbUVB) therapy is appropriate for most children with psoriasis, though no set guidelines exist. Psoralen/UVA (PUVA), though, should be avoided unless in severe or refractory disease, given known long-term risk of carcinogenesis and cataracts (the ocular lens is more permeable in young).

nbUVB protocols vary, but the typical starting dose in children is ≤ 70% of minimal erythema dose (MED), which may be increased gradually by 10-20% per session.10-11  Frequency and duration of treatment vary, but Dr. Cortelazzi generally performs 2-3 sessions per week for several months.

In psoriasis, nbUVB is considered a first-line treatment diffuse disease,12  and was effective and safe in retrospective study of 88 pediatric psoriasis patients; 51% of children given nbUVB had full clearance, and 92% achieved greater than 75% improvement.13  Adjunct topical therapies, applied after nbUVB sessions, enhance efficacy. If the patient cannot reach the clinic or hospital, home units or supervised natural sunlight for 10-15 minutes can also be considered.

NO: Dr. Venturini opposed phototherapy in children, primarily because overall data on safety and efficacy are limited as RCTs are lacking. Appropriate patient selection is vital, and absolute contraindications include photosensitivity and cancer-predisposing genodermatoses.

Aside from known acute cutaneous adverse events (AEs), young children often exhibit poor eyewear compliance and may experience anxiety. Long-term AEs remain unknown. Though no relationship between nbUVB and skin cancer has yet been detected,14,15 children may require extended nbUVB treatment and additional immunosuppressives, confounding the theoretical risk. PUVA clearly carries higher risk of non-melanoma skin cancer and cataracts, and therefore should be approached with extreme caution.14-16

Interestingly, there are reports of increased dysplastic melanocytic nevi occurring in neonatal blue light therapy (spectrum adjacent to UV light) treating neonatal hyperbilirubinemia, highlighting the potential risk of phototherapy.17 Overall, true carcinogenic potential with repeat UV exposure remains unclear and there may be a significant delay from treatment initiation to carcinogenesis.

In summary, both Dr. Cortelazzi and Dr. Venturini agree that extra caution and individualized risk assessments are important in children, and phototherapy should be considered only after weighing all risks and benefits.

 

SECTION PEARLS:

  • Though much of our data comes from adult populations and studies, approved biologics appear safe when used in pediatric psoriasis, even during the COVID-19 pandemic.
  • Phase 3 trials of secukinumab, both low and high dose, demonstrate safety and efficacy in pediatric psoriasis, with rapid and durable PASI-75 response exceeding 85%.
  • Though nbUVB appears safe and effective for children with psoriasis, no randomized control trials exist. Careful patient selection and individualized treatment plans are required.
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