Phototherapy Effective as Treatment for Moderate to Severe Eczema in Children

Phototherapy is an effective treatment modality for individuals with moderate-to-severe atopic dermatitis within the Asian pediatric population, according to recent findings, though limitations to the use of phototherapy include the necessity of prior counseling and careful selection of candidates.¹

These findings resulted from retrospective research led by Shi Yun Chia of the department of paediatric medicine at KK Women's and Children's Hospital in Singapore. The conclusion that Chia et al. reached was that phototherpy should be considered by clinicians as a second-line therapy over oral systemic immunosuppressants.

The investigators noted prior studies which reviewed different phototherapy modalities like broadband ultraviolet B (BBUVB), narrowband ultraviolet B (NBUVB), ultraviolet A (UVA), and others.² Nevertheless, they cited a lack of reports assessing the efficacy of phototherapy among Asian children specifically.

“KKH is the largest tertiary pediatric hospital in Singapore, with a total bed capacity of 830 and sees a large number of pediatric patients with moderate to severe (atopic dermatitis),” Chia and colleagues wrote. “Data over a 4-year period, from 2017 to 2020, were reviewed. We assessed the clinical findings, both objective and subjective outcome measures, as well as the side effects encountered in our cohort of patients.”

Background and Design

The investigators assessed patients in the age range of 18 years and younger who also had atopic dermatitis and underwent phototherapy while at the KK Women's and Children's Hospital in Singapore over a 4-year period. The period was from January 2017 - December 2020.

The phototherapy database at KKH was used to find the subjects, and dermatology nurses or clinicians were instructed to take clinical photographs of the participants prior to and following their phototherapy. An evaluation by pediatric dermatologists was done regarding atopic dermatitis severity prior to and following subjects’ treatment through the 5-point Investigator Global Assessment (IGA) scale or the Eczema Area and Severity Index (EASI).

The research team also assessed demographic data as well as disease-related elements such as duration and associated medical issues. The team also looked into data related to duration of treatment, phototherapy modalities, number of sessions, maximum utilized dosage, response to therapy, and any new complications.

They administered NBUVB in a phototherapy cabinet, having the initial doses ranging from 250 - 400 mJ/cm² based on Fitzpatrick skin types II–VI, with dose increases of 10%–20% depending on whether treatments led to no or slight erythema. A combination of UVA and NBUVB was given to some subjects as well, with initial doses of UVA being 1 J/cm² and NBUVB being 100 mJ/cm², irrespective of Fitzpatrick skin type.

The investigators also had dose increment raises of 0.5–1 J/cm² for UVA and 50–100 mJ/cm² for NBUVB provided there had been no or slight erythema resulting from prior treatments. They used photochemotherapy (psoralen + UVA, or PUVA) in cases where severe hand and foot dermatitis was noted, using a unit with UVA radiators alongside soak PUVA.

The research team noted that initial UVA dose was set to be 1 J/cm² regardless of subjects’ skin types, adding that increments of 0.5–1 J/cm² were included if prior therapies led to no or slight erythema. Twice-per-week phototherapy treatments were begun within the initial phase, reducing to a single treatment per-week upon clinical improvement of patients’ atopic dermatitis.

Findings

Overall, the investigators included 62 participants who were within the age range of 4 - 16 years. They reported 60% to be male and 40% to be female, noting that the majority of these subjects had moderate to severe disease.

Specifically, the research team found that 60.3% had an initial body surface area (BSA) involvement of about 31%–60%, adding that 13.8% had BSA involvement of about 61%–90%. The mean reductions in EASI scores among participants who were given NBUVB and combined UVA and NBUVB phototherapy were noted by the team as 11.4 and 7.9, respectively.

The investigators identified the most common side effects as pruritus, xerosis, erythema, and pain. They reported that 2 individuals were treated with photochemotherapy (psoralen + UVA) (PUVA) and then reported post-UVA burns which resulted in discontinuation of their treatment.

The research team concluded that 56.9% had been shown to be successful in their treatment, adding that significant improvements in IGA and EASI scores had been observed. Therapy regimen compliance had been strong among 86.2% of participants, less strong among 12%, and there had been 3.4% lost to follow-up.

“There are limitations to the administration of phototherapy, requiring prior counseling and careful selection of appropriate patients for phototherapy,” they wrote. “It is generally well tolerated in the Asian pediatric patient with (atopic dermatitis), and should be considered as a second-line treatment over oral systemic immunosuppressants.”

References

1. ^{Chia SY, Chee EEC, Wee LWY, Koh MJA. Phototherapy for the treatment of atopic dermatitis in Singaporean children and adolescents. Photodermatol Photoimmunol Photomed. 2024; 40:e12986. doi:10.1111/phpp.12986.}
2. ^{Majoie IM, Oldhoff JM, van Weelden H, et al. Narrowband ultraviolet B and medium-dose ultraviolet A1 are equally effective in the treatment of moderate to severe atopic dermatitis. J Am Acad Dermatol. 2009; 60: 77-84.}