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Ultraviolet light therapy

Ultraviolet light therapy, also known as phototherapy, is a medical treatment that utilizes controlled exposure to ultraviolet (UV) radiation—specifically UVA (320–400 nm) and UVB (280–315 nm) wavelengths—to manage inflammatory skin disorders by reducing inflammation, suppressing immune responses, and slowing excessive skin cell growth.^[1] This non-invasive approach has been a cornerstone of dermatology since the early 20th century, pioneered by Niels Finsen who received the 1903 Nobel Prize for his work on light therapy for skin conditions, offering an effective alternative or adjunct to topical and systemic medications for conditions unresponsive to other therapies.^[1] Primarily administered in clinical settings under medical supervision, it involves sessions where affected skin areas are exposed to artificial UV light sources for precise durations, typically ranging from seconds to minutes, with treatment courses spanning weeks to achieve remission.^[2] The therapy encompasses several types tailored to specific needs: broadband UVB (BB-UVB, 280–350 nm) for general use; narrowband UVB (NB-UVB, 311–313 nm), which is more targeted and effective with fewer sessions; UVA alone or in combination with psoralen (PUVA), a photosensitizing drug that enhances UV penetration; and specialized variants like excimer lasers for localized lesions or UVA-1 (340–400 nm) for deeper dermal conditions.^[1] NB-UVB, in particular, is widely preferred for its superior efficacy in clearing plaques and prolonging remissions compared to broadband UVB.^[3] Common indications include moderate-to-severe psoriasis, where it slows hyperproliferation of keratinocytes; atopic dermatitis (eczema), alleviating itch and inflammation; vitiligo, promoting repigmentation in up to 35% of cases; and cutaneous T-cell lymphoma like mycosis fungoides, inducing T-cell apoptosis.^[1]^[3] Beyond dermatology, UV phototherapy is used for certain graft-versus-host diseases.^[1] Mechanistically, UVB radiation induces DNA damage in rapidly dividing cells, triggering anti-inflammatory cytokines and apoptosis in immune cells, while PUVA forms photoadducts that cross-link DNA and further immunosuppress.^[1] Benefits include high clearance rates—often 70–90% for psoriasis after 20–30 sessions—cost-effectiveness, and minimal systemic side effects, making it suitable for children, pregnant individuals (with precautions such as folate supplementation for NB-UVB), and those avoiding immunosuppressants.^[3]^[2] However, risks involve short-term erythema, burning, and pruritus, alongside long-term concerns like premature photoaging and increased skin cancer risk, particularly squamous cell carcinoma with cumulative PUVA exposure exceeding 150 treatments.^[1] Protective measures, such as goggles and gradual dose escalation using the minimal erythema dose, mitigate these hazards, with NB-UVB showing a safer profile than PUVA.^[1] Ongoing research as of 2025 emphasizes combination therapies, home units—which studies like the LITE trial show are as effective as office-based treatment for psoriasis with higher adherence—and emerging applications such as UVB for stabilizing inflammation in multiple sclerosis, though professional oversight remains essential to balance efficacy and safety.^[3]^[4]^[5]

Introduction and History

Definition and Principles

Ultraviolet light therapy, also known as phototherapy, is a medical treatment that involves the controlled exposure of the skin to specific wavelengths of ultraviolet (UV) radiation, primarily in the UVA and UVB ranges, to manage various dermatological and other diseases.^[1] This approach leverages non-ionizing radiation to modulate skin cell activity and immune responses, offering a targeted alternative to systemic medications for conditions such as psoriasis and eczema.^[6] The basic principles of ultraviolet light therapy are rooted in photobiology, the study of how light interacts with biological tissues. UV radiation is absorbed by chromophores in the skin, such as DNA in cell nuclei and proteins in cellular structures, leading to photochemical reactions that alter cellular function and promote therapeutic effects like reduced inflammation and normalized skin proliferation.^[1] Unlike natural sunlight exposure, which delivers variable and uncontrolled doses of UV radiation alongside visible and infrared light, ultraviolet light therapy employs artificial sources—such as fluorescent lamps or LEDs in calibrated devices—to ensure precise dosing, wavelength selection, and minimal risk of overexposure or burns.^[1] This controlled delivery allows clinicians to tailor treatments to individual patient needs, optimizing efficacy while mitigating potential side effects.^[6] The UV spectrum is divided into three main bands based on wavelength: UVA (315–400 nm), UVB (280–315 nm), and UVC (100–280 nm).^[7] In therapeutic applications, only UVA and UVB are utilized, as UVC is highly energetic, almost entirely absorbed by the ozone layer, and poses significant risks of cellular damage without clinical benefits in controlled settings.^[8]

Historical Development

The origins of ultraviolet light therapy can be traced to the early 20th century, when Danish physician Niels Ryberg Finsen developed innovative phototherapy techniques using concentrated ultraviolet (UV) light to treat skin diseases. Finsen, motivated by his own battle with a chronic illness, experimented with carbon arc lamps to deliver "chemical rays"—early terminology for UV radiation—and achieved notable success in treating lupus vulgaris, a tuberculous skin infection previously resistant to other interventions. His systematic application of filtered UV light to inhibit bacterial growth in affected tissues earned him the Nobel Prize in Physiology or Medicine in 1903, establishing phototherapy as a legitimate medical practice and inspiring the founding of the Finsen Institute in Copenhagen for further research.^[9]^[10] From the 1920s through the 1950s, artificial UV sources revolutionized treatment accessibility, moving beyond natural sunlight (heliotherapy) to controlled applications with mercury arc lamps and similar devices. These advancements targeted conditions like cutaneous tuberculosis and rickets; for tuberculosis, UV's antimicrobial properties were harnessed to reduce lesions, while for rickets, exposure promoted vitamin D synthesis in the skin, addressing widespread deficiencies in industrialized populations with limited sun access. Clinical adoption grew rapidly, with institutions integrating UV cabinets and lamps into sanatorium protocols, supported by evidence from controlled studies demonstrating improved outcomes over conventional therapies alone.^[11]^[12]^[13] A pivotal evolution occurred in the 1970s with the introduction of psoralen plus UVA (PUVA) therapy, pioneered by dermatologists John A. Parrish and Thomas B. Fitzpatrick at Harvard Medical School. Building on earlier psoralen research, they combined oral or topical psoralens—photosensitizing agents—with high-intensity UVA irradiation, coining the term "PUVA" in 1974 after demonstrating its efficacy in clearing severe psoriasis plaques in clinical trials involving over 1,300 patients. This photochemotherapy approach marked a shift toward targeted wavelength specificity and systemic enhancement, dramatically improving response rates and becoming a cornerstone for refractory dermatoses.^[6]^[14] The late 20th and early 21st centuries brought refinements in UV delivery, including the widespread adoption of narrowband UVB (NB-UVB) therapy emitting primarily at 311 nm, which emerged from spectral studies in the 1980s and gained traction in the 1990s for its superior therapeutic index over broadband UVB—offering faster clearance with fewer sessions and reduced erythema risk. NB-UVB lamps, developed by Philips, received FDA clearance for psoriasis treatment in the United States by 1996, accelerating global standardization. Around 2010, the FDA approved targeted home-use devices like the Levia Personal Therapy System, enabling supervised self-administration and improving patient convenience for maintenance therapy.^[15]^[16]^[17] Parallel to these innovations, professional organizations have shaped safe implementation since the 1980s, with the American Academy of Dermatology (AAD) issuing evolving guidelines on dosimetry, patient selection, and monitoring to mitigate risks like photoaging. These protocols, refined through consensus statements and updated periodically (e.g., joint AAD-National Psoriasis Foundation guidelines in 2019), reflect accumulating evidence from long-term registries and underscore phototherapy's integration into evidence-based dermatologic care. More recently, the 2024 Light Treatment Effectiveness (LITE) study confirmed that home-based NB-UVB phototherapy is noninferior to office-based treatment for plaque and guttate psoriasis, demonstrating high effectiveness, safety, improved patient adherence, and reduced costs.^[18]^[19]^[20]

Scientific Foundations

Types of Ultraviolet Radiation

Ultraviolet radiation is classified into three main types based on wavelength: UVA (320–400 nm), UVB (280–320 nm), and UVC (100–280 nm).^[1] UVA represents the longest wavelengths in this spectrum, while UVC has the shortest.^[21] In therapeutic contexts, UVC is generally excluded due to its strong germicidal properties but minimal penetration into human skin, limiting its utility for internal tissue treatment.^[22] UVA is further subdivided into UVA1 (340–400 nm) and UVA2 (320–340 nm), allowing for targeted applications based on penetration and energy differences within the band.^[23] UVB is categorized into broadband (280–320 nm), which emits a wider spectrum, and narrowband (311–313 nm), which focuses on a specific peak for more precise delivery.^[24] These subdivisions enable customization in phototherapy devices to match therapeutic needs. Physically, UV radiation's energy is inversely proportional to its wavelength, meaning shorter-wavelength UVB photons carry higher energy than longer-wavelength UVA photons, resulting in greater absorption at the skin's surface.^[22] UVB is primarily absorbed in the epidermis (depths of ~0.02–0.1 mm), while UVA penetrates deeper into the papillary dermis (up to ~1 mm).^[25] The Earth's ozone layer absorbs most UVC and a significant portion of UVB, allowing primarily UVA to reach the surface, though artificial sources bypass this natural filtration.^[22] UV doses in therapy are measured in joules per square centimeter (J/cm²) for UVA and millijoules per square centimeter (mJ/cm²) for UVB to quantify exposure accurately.^[26] Artificial sources for UV in therapy include fluorescent lamps, which produce broadband emission spectra suitable for general UVB delivery; light-emitting diodes (LEDs), offering compact and efficient narrowband output; and excimer lasers, providing monochromatic radiation (e.g., 308 nm for targeted UVB).^[1] These sources vary in spectral purity, with fluorescent lamps emitting a continuum and excimer lasers delivering precise wavelengths for localized treatment.^[27]

Cellular and Immunological Mechanisms

Ultraviolet B (UVB) radiation primarily exerts its cellular effects through direct absorption by DNA in keratinocytes, leading to the formation of cyclobutane pyrimidine dimers (CPDs) and (6-4) photoproducts, which distort the DNA helix and impede replication and transcription.^[28] These lesions activate DNA damage response pathways, including ataxia-telangiectasia and Rad3-related (ATR) kinase signaling, culminating in p53-mediated apoptosis to eliminate damaged or hyperproliferative cells.^[28] In therapeutic contexts, this programmed cell death selectively targets malignant or atypical keratinocytes, reducing pathological skin proliferation without widespread tissue destruction.^[29] In contrast, ultraviolet A (UVA) radiation penetrates deeper into the dermis and induces cellular damage indirectly by exciting endogenous chromophores, generating reactive oxygen species (ROS) such as singlet oxygen and superoxide anions.^[30] These ROS cause oxidative modifications to DNA bases (e.g., 8-oxoguanine), lipids, and proteins, promoting a broader immunomodulatory effect compared to UVB's epidermal-focused DNA lesions.^[27] While UVB directly triggers apoptosis via DNA strand breaks, UVA's ROS-mediated pathways activate transcription factors like AP-1 and NF-κB, influencing cell survival and inflammation in deeper skin layers.^[27] At the immunological level, UV exposure suppresses adaptive immunity by inhibiting effector T-cell proliferation and differentiation; for instance, suberythemal UVB doses reduce CD4+ and CD8+ T-cell expansion in draining lymph nodes by 2- to 3-fold, limiting inflammatory responses.^[31] This suppression extends to cytokine modulation, where UVB decreases pro-inflammatory cytokines such as IL-17 and TNF-α while elevating anti-inflammatory IL-10, altering the Th17/Th1 balance to dampen hypersensitivity.^[32] Additionally, UV induces regulatory T-cells (Tregs), increasing their frequency among CD4+ cells post-exposure, which further promotes tolerance through IL-10 and TGF-β secretion.^[32] UV radiation also alters antigen-presenting cells (APCs), particularly Langerhans cells, by depleting their density and downregulating MHC class II expression, impairing antigen processing and T-cell activation.^[30] UVA achieves this via ROS-induced apoptosis in T-cells and APCs, while UVB acts through DNA damage signaling that reduces APC migration to lymph nodes.^[30] These changes collectively foster systemic immunosuppression, beneficial in autoimmune skin conditions but requiring careful dosing.^[32] The therapeutic efficacy of UV light follows a biphasic dose-response curve: low doses (below the minimal erythema dose, MED) suppress immunity without inducing inflammation, enhancing tolerance via Treg induction, whereas doses exceeding the MED (typically 200–600 mJ/cm² depending on skin type) provoke erythema and pro-inflammatory cytokine release.^[33] The MED serves as a critical threshold for calibrating treatments, ensuring immunosuppressive benefits while minimizing oxidative or apoptotic overload.^[33] This dose dependency underscores the need for individualized protocols to harness UV's immunomodulatory potential.^[33]

Therapeutic Modalities

UVB Phototherapy

Ultraviolet B (UVB) phototherapy employs radiation in the 280-320 nm wavelength range to treat photoresponsive skin disorders by inducing controlled cellular responses in the epidermis. This modality includes two primary variants: broadband UVB (BB-UVB), which emits a spectrum from approximately 280-320 nm and has been a standard treatment option for decades due to its broad availability, and narrowband UVB (NB-UVB), which focuses on a narrower peak at 311-313 nm for enhanced therapeutic precision. NB-UVB, developed following action spectrum research in the early 1980s that identified optimal wavelengths for efficacy, demonstrates superior clinical outcomes compared to BB-UVB, often requiring fewer treatment sessions while reducing the risk of erythema.^[34]^[6] Procedurally, UVB phototherapy is delivered through whole-body cabinets for extensive skin involvement or localized hand/foot units for targeted areas, allowing for efficient exposure without requiring patient immobilization. The initial dose is calculated as 50-70% of the patient's minimal erythema dose (MED), determined via skin type assessment or phototesting, to establish a safe baseline. Subsequent sessions feature incremental dose escalations of 20-40% based on tolerance and response, ensuring progressive adaptation while monitoring for mild erythema as a guide to efficacy.^[35]^[36] This therapy is primarily indicated for psoriasis, vitiligo, and atopic dermatitis, where it promotes repigmentation, plaque clearance, and inflammation reduction, respectively. Treatments typically occur 2-3 times weekly, spaced at least 48 hours apart to allow skin recovery, with courses lasting 12-24 weeks to achieve remission in responsive cases.^[24]^[36] A key advantage of UVB phototherapy is that it requires no photosensitizing agents, avoiding associated systemic preparation and potential toxicities. Furthermore, it offers lower overall costs relative to biologic or systemic therapies, making it accessible for long-term management in outpatient settings. UVB exerts its immunomodulatory effects primarily through DNA photoproducts in keratinocytes, as explored in the Cellular and Immunological Mechanisms section.^[37]^[36]

PUVA Therapy

PUVA therapy, also known as psoralen plus ultraviolet A photochemotherapy, involves the administration of a photosensitizing psoralen compound followed by controlled exposure to UVA radiation (320–400 nm) to treat various dermatological conditions, particularly severe psoriasis.^[38] The therapy relies on the synergistic interaction between psoralen and UVA to achieve therapeutic effects deeper in the skin than standalone phototherapy.^[39] The key components of PUVA include psoralen, most commonly 8-methoxypsoralen (8-MOP), which is administered orally at a dose of 0.4–0.6 mg/kg body weight or applied topically in certain variants.^[38] Oral psoralen is typically ingested 75 minutes to 2 hours prior to UVA exposure, allowing sufficient time for absorption and distribution to enhance light penetration into the epidermis and dermis.^[38]^[39] Alternative forms, such as 5-methoxypsoralen (5-MOP), may be used for reduced side effect profiles in some protocols.^[39] The standard protocol begins with determining the initial UVA dose based on the patient's Fitzpatrick skin type to minimize erythema risk, typically starting at 0.5–5 J/cm² (e.g., lower for fairer skin types like I–II and higher for darker types V–VI).^[38] Subsequent doses are incrementally increased by 0.5–1.5 J/cm² per session as tolerated, with treatments scheduled 2–3 times weekly and at least 48 hours apart to allow skin recovery.^[38] A full course may involve up to 100–150 total treatments across multiple cycles for chronic management, though clearance often occurs after 25–30 sessions.^[39] A distinctive feature of PUVA is the photochemical reaction where UVA activates psoralen to form covalent conjugates with DNA pyrimidine bases, particularly thymine, leading to DNA crosslinks that inhibit replication and prolong antiproliferative effects in keratinocytes.^[40] This mechanism contributes to its superior efficacy in clearing severe, plaque-type psoriasis, with response rates often exceeding 80% in clinical settings, though it necessitates vigilant monitoring of patient response and skin integrity during treatment.^[38] The bath PUVA variant offers a localized alternative, where patients soak in a dilute psoralen solution (e.g., 50 mg 8-MOP dissolved in 100 liters of warm water at 37°C) for 15–30 minutes to limit systemic exposure, followed immediately by UVA irradiation without rinsing.^[38] This approach is particularly suited for hand/foot involvement or patients intolerant to oral psoralen.^[39]

Emerging Modalities

UVA1 therapy, utilizing wavelengths between 340 and 400 nm, represents an advancement in ultraviolet phototherapy by delivering targeted long-wave UVA radiation without the need for psoralen sensitization. This modality employs varying dose intensities—high doses exceeding 70 J/cm² up to 130 J/cm², medium doses of 30-60 J/cm², and low doses below 30 J/cm²—to penetrate deeper skin layers and modulate immune responses in fibrotic and inflammatory conditions. Clinical studies have demonstrated its efficacy for scleroderma, where medium- to high-dose regimens reduce skin thickening and improve flexibility, and for atopic dermatitis, where medium doses alleviate severe flares by suppressing T-cell activity and cytokine production.^[26]^[23]^[41] The excimer laser, operating at 308 nm to provide targeted narrowband UVB, enables precise treatment of localized lesions such as those in psoriasis, minimizing exposure to surrounding healthy skin. Approved by the FDA in 2000 for psoriasis management, this device delivers higher fluences directly to affected areas, achieving clearance in fewer sessions compared to conventional UVB phototherapy while reducing risks like erythema in untreated regions. Its selectivity stems from the ability to adjust energy output to the minimal erythema dose specific to psoriatic plaques, promoting faster repigmentation and lesion resolution with enhanced patient tolerance.^[42]^[43]^[44] Home-based ultraviolet devices have evolved since the mid-2010s, incorporating LED and compact fluorescent technologies for convenient self-administration of narrowband UVB therapy. The Zerigo Health Phototherapy System, FDA-cleared in 2017, exemplifies this shift with its portable design and integrated PreciZeDose technology, which automates dosing via a connected app to track treatments and ensure adherence. Regulatory advancements in the 2020s, including endorsements from clinical guidelines and studies like the LITE trial, affirm the efficacy of these units, showing comparable outcomes to clinic-based therapy for psoriasis and eczema with improved accessibility and cost-effectiveness.^[45]^[46]^[47] Hybrids combining ultraviolet activation with photodynamic therapy, particularly using porphyrin-based photosensitizers, are under investigation for non-melanoma skin cancers. These approaches leverage UVA to excite endogenous or exogenous porphyrins, generating reactive oxygen species to induce selective tumor cell apoptosis while sparing deeper tissues. As of 2023, clinical trials explore UV-activated porphyrin formulations in actinic keratosis and basal cell carcinoma, demonstrating promising response rates in early-phase studies with reduced recurrence compared to standard PDT.^[48]^[49]^[50]

Clinical Applications

Dermatological Conditions

Ultraviolet light therapy, particularly narrowband UVB (NB-UVB), serves as a first-line treatment for moderate-to-severe plaque psoriasis, offering significant clearance rates in clinical practice. A systematic review and meta-analysis of randomized controlled trials reported a 68% complete clearance rate with NB-UVB (95% CI 57-78%), typically achieved after 20-30 sessions.^[51] However, relapse occurs in approximately 50% of patients within 6 months post-treatment, necessitating maintenance therapy or combination approaches for sustained remission.^[52] For vitiligo, NB-UVB phototherapy induces repigmentation in 50-75% of cases, with superior outcomes observed in facial lesions due to their higher responsiveness.^[53] A 2017 systematic review and meta-analysis of prospective studies found that at least mild repigmentation (≥25%) was achieved in 74.2% of patients after 6 months of NB-UVB (95% CI 64.5-83.9%, based on 11 studies with 232 patients), while marked repigmentation (≥75%) occurred in 44.2% of facial lesions after ≥6 months.^[53] These results highlight NB-UVB's role as a standard monotherapy, especially for localized or generalized stable vitiligo, with progressive improvement over 6-12 months. In atopic dermatitis and eczema, NB-UVB provides symptom reduction through immunomodulation, suppressing T-cell activity and cytokine release in the skin.^[54] It is particularly beneficial for moderate-to-severe cases unresponsive to topicals, with evidence from randomized trials showing improvements in physician-assessed severity scores (e.g., mean difference -9.4 on a 0-90 scale vs. placebo after 12 weeks).^[55] For children, NB-UVB is preferred over PUVA due to its lower long-term risk of skin carcinogenesis, while maintaining comparable efficacy as a second-line option.^[56] Among other dermatological applications, PUVA therapy is effective for early-stage mycosis fungoides (cutaneous T-cell lymphoma), achieving response rates around 80% in patch and plaque stages.^[57] Consensus guidelines based on multiple randomized and observational studies report complete response rates of 85% in stage IA, 65% in stage IB, and 85% in stage IIA disease, often within 2-3 months of treatment.^[57] Recent reviews up to 2023 confirm these outcomes from randomized controlled trials, positioning PUVA as a key skin-directed therapy for indolent presentations.^[58]

Non-Dermatological Uses

Ultraviolet light therapy has been employed in the treatment of neonatal jaundice since the 1960s, when it was first introduced as a non-invasive method to manage hyperbilirubinemia in newborns.^[59] This approach utilizes blue light to convert bilirubin into water-soluble photoisomers through a process known as photoisomerization, facilitating its excretion via urine and bile without the need for exchange transfusion in most cases.^[60] Phototherapy has become the standard intervention for over 95% of neonates requiring treatment for significant hyperbilirubinemia, significantly reducing the risk of kernicterus and associated neurological damage.^[61] UV phototherapy, particularly narrowband UVB or PUVA, is used for the cutaneous manifestations of graft-versus-host disease (GVHD) following hematopoietic stem cell transplantation. It helps reduce inflammation and immunosuppression in affected skin, with response rates of 50-80% in chronic GVHD cases, often as an adjunct to systemic therapies.^[62] A 2024 systematic review confirms its efficacy in both acute and chronic forms, positioning it as a valuable non-pharmacologic option for steroid-refractory patients. In conditions involving vitamin D deficiency, such as osteoporosis or malabsorption syndromes like cystic fibrosis, controlled UVB exposure serves as an alternative to oral supplementation by promoting cutaneous synthesis of vitamin D3.^[63] This therapy is particularly beneficial for patients with impaired gastrointestinal absorption, where one minimal erythemal dose (MED) of UVB applied to a limited body surface area can equate to the vitamin D production from 600–1000 IU of oral intake.^[63] Dosing regimens typically involve 1-3 MED exposures quarterly to maintain adequate serum 25-hydroxyvitamin D levels while minimizing risks of overexposure.^[64] UV-C irradiation has shown promise in wound healing and antimicrobial applications for chronic ulcers, where it directly targets bacterial colonization without significantly harming surrounding host tissue.^[27] Clinical trials demonstrate that UV-C treatments can achieve up to a 99% reduction in bacterial viability and load in infected chronic wounds, such as pressure ulcers and venous leg ulcers, thereby accelerating healing and reducing infection-related complications.^[65] In the 2020s, experimental applications of UV-C have extended to disinfection protocols for SARS-CoV-2, with studies confirming its efficacy in inactivating the virus on surfaces and in air, offering a chemical-free method to mitigate environmental transmission in healthcare settings.^[66] For psychiatric conditions like seasonal affective disorder (SAD), full-spectrum ultraviolet light therapy has been investigated as an adjunct to traditional bright light treatment, potentially enhancing mood regulation through vitamin D modulation.^[67] Studies from 2015 indicate modest improvements in depressive symptoms among SAD patients receiving UV-inclusive light exposure, with benefits observed in both typical and atypical symptom profiles compared to non-UV light alone.^[68] This approach leverages the role of UV in systemic physiological responses, though it remains secondary to standard visible light protocols due to safety considerations.^[67]

Equipment and Administration

Devices and Technology

Whole-body cabins for ultraviolet light therapy typically consist of vertical arrays of fluorescent tubes arranged in panels surrounding the patient, providing uniform exposure to large skin areas. These cabins commonly use Philips TL-01 lamps, which emit narrowband UVB radiation peaking at 311 nm, with irradiance levels at the skin surface ranging from 5 to 20 mW/cm² depending on the device configuration and distance.^[69]^[70] Filters or reflective surfaces within the cabin help select specific ultraviolet wavelengths, such as narrowband UVB or broadband UVA, while directing light efficiently toward the patient.^[71] Targeted devices enable localized treatment of specific skin areas, reducing exposure to healthy tissue. Excimer lasers, such as the XTRAC system operating at 308 nm, deliver a focused beam with a spot size of approximately 2-3 cm², suitable for precise applications on small lesions.^[72] Hand-held units, often incorporating similar excimer technology or portable fluorescent sources, are designed for treating hard-to-reach areas like nails or the scalp, offering mobility and controlled application.^[73] Clinical settings primarily utilize stationary whole-body or targeted systems for supervised administration, whereas home devices provide convenience for ongoing maintenance therapy. Portable panels, exemplified by the Daavlin 7 Series, are compact units with integrated timers and FDA clearance for home use, accommodating narrowband UVB lamps in configurations of 4 to 12 tubes.^[74] Post-2020 advancements in LED-based ultraviolet sources have introduced greater energy efficiency and longevity compared to traditional fluorescent tubes, with lower power consumption and reduced heat output in emerging portable designs.^[75] Quality control in ultraviolet therapy devices ensures consistent and safe output through regular maintenance protocols. Spectral calibration verifies the emission wavelength using reference standards, while built-in dosimetry sensors monitor irradiance in real-time to maintain treatment accuracy.^[76] Shielding elements, such as acrylic guards over lamps and absorbent interior linings, minimize stray ultraviolet radiation leakage from the cabin or device enclosure.^[71]

Treatment Protocols and Dosimetry

Patient preparation for ultraviolet light therapy begins with assessment of the Fitzpatrick skin type, classified from I (always burns, never tans) to VI (deeply pigmented, never burns), to guide initial dosing and minimize adverse reactions.^[77] Eye protection, such as opaque goggles, is required during all sessions to prevent photokeratitis and cataracts, particularly in PUVA therapy where psoralens increase ocular sensitivity.^[1] The minimal erythema dose (MED) is determined through serial exposures on unexposed skin, typically the back or buttocks, with doses escalating in increments (e.g., 25-50% steps) until the lowest dose producing perceptible erythema 24 hours later is identified; this MED informs personalized starting doses.^[78] Dosimetry in UV therapy involves measuring and tracking cumulative exposure in joules per square centimeter (J/cm²) to ensure therapeutic efficacy while avoiding overdose. Starting doses are sub-erythemal, often 50-70% of the MED for narrowband UVB (NB-UVB) or 0.5-4 J/cm² based on skin type for PUVA, with adjustments for body surface area in targeted treatments. Escalation follows standardized rules, such as 20-40% increases per session for NB-UVB if no erythema occurs, or fixed increments of 0.5-1.5 J/cm² for PUVA, capped by maximum doses per skin type (e.g., 8-20 J/cm²).^[79]^[77] Session logistics emphasize controlled delivery to optimize outcomes. Exposure times typically range from 1-10 minutes, depending on device output and skin type, with treatments administered 2-3 times weekly and at least 48 hours between sessions to allow skin recovery. For PUVA, total courses are limited to avoid excessive cumulative exposure, often not exceeding 200 sessions lifetime due to long-term risks, while NB-UVB courses may total 30-40 sessions for clearance.^[79]^[77]^[1] Monitoring during therapy includes regular assessment of skin response using an erythema grading scale from 0 (no erythema) to 4 (severe erythema with blistering or edema), with doses held or reduced (e.g., by 25%) if grade 2 or higher persists beyond 24 hours. Post-remission maintenance therapy involves tapering to weekly or biweekly sessions at 50% of the clearing dose to prolong remission, typically for 3-6 months or until relapse.^[80]^[79]

Safety and Risk Management

Acute Side Effects

Acute side effects of ultraviolet light therapy encompass transient reactions that typically manifest shortly after exposure and resolve within days, primarily affecting the skin but occasionally involving systemic or ocular symptoms. These effects are generally mild to moderate and can be managed to support treatment adherence, with recognition aiding in prompt intervention. Common manifestations include dermatological responses like erythema and pruritus across UVB and PUVA modalities, alongside modality-specific issues such as nausea in PUVA. Erythema, characterized by skin redness and warmth akin to sunburn, represents the predominant acute side effect in UVB phototherapy. It typically peaks between 8 and 24 hours post-exposure, often accompanied by a burning sensation, tenderness, or mild swelling, and resolves over 3 to 7 days. This reaction occurs in approximately 10-40% of patients, with higher incidence in those with fair skin types (I-II), obesity, or concurrent use of photosensitizing medications. Management involves cool compresses, topical emollients, and low-potency corticosteroids to reduce discomfort and inflammation, while severe cases may necessitate temporary dose reduction or treatment pause.^[1]^[77]^[81] Pruritus and skin dryness frequently accompany or follow erythema in UV therapy, affecting up to 30% of patients and contributing to overall discomfort during sessions. These symptoms arise from disruption of the skin barrier and increased transepidermal water loss, manifesting as itching or scaling shortly after exposure. Emollients and moisturizers applied post-treatment effectively alleviate dryness and pruritus by restoring hydration and soothing irritation, often preventing escalation to more severe reactions.^[82]^[83] In PUVA therapy, nausea emerges as a distinctive acute side effect attributable to oral psoralen ingestion, occurring in 5-30% of patients and potentially accompanied by vomiting or gastrointestinal upset within hours of administration. This is mitigated by consuming psoralen with food, milk, or a full meal to slow absorption, or by prophylactic antiemetics such as metoclopramide.^[84]^[85] Ocular effects, including conjunctivitis or keratitis, may develop if eyes remain unprotected during exposure, presenting as redness, tearing, or discomfort within hours. Such reactions are rare, affecting fewer than 1% of patients when UV-opaque goggles are consistently worn, as protective eyewear effectively blocks harmful wavelengths.^[1] Protocol adjustments, such as dose titration based on minimal erythema dose, can help minimize the occurrence and severity of these acute effects.

Long-term Risks

Long-term exposure to ultraviolet (UV) light in therapies such as PUVA has been associated with an elevated risk of skin cancer, particularly squamous cell carcinoma (SCC). Studies indicate that the relative risk of SCC increases substantially with cumulative doses, with a hazard ratio of approximately 4.44 for patients receiving 250 or more PUVA sessions compared to fewer, based on long-term follow-up in patients with mycosis fungoides.^[86] Earlier cohort analyses have reported even higher risks, such as a nearly 13-fold increase in SCC for high-dose PUVA groups relative to low-dose exposure.^[87] For melanoma, the risk is more debated in UV therapies overall, but evidence from PUVA cohorts shows an elevation after 250 or more treatments, emerging about 15 years post-initiation.^[88] Regarding UVB phototherapy, while melanoma risk remains controversial, some meta-analyses and reviews up to 2020 and a 2024 multi-center registry study suggest a potential elevation with high cumulative doses, though many large studies from 2020-2024 find no significant overall increase.^[89]^[16] Photoaging represents another cumulative effect of repeated UV exposures, especially from UVA components in PUVA, which generate reactive oxygen species (ROS) leading to premature wrinkling and solar elastosis. These changes, characterized by dermal matrix degradation and elastic fiber accumulation, become clinically visible after approximately 100 or more treatment sessions, mirroring chronic sun damage but accelerated by therapeutic dosing.^[90] UVA-induced ROS disrupt collagen and elastin integrity, contributing to sagging and leathery skin texture over time.^[91] Systemic effects from prolonged UV therapy include potential immunosuppression, which may heighten susceptibility to infections, although such complications are rare in clinical practice. UV radiation suppresses T-cell function and antigen presentation, theoretically increasing infection risk, but bacterial or viral outbreaks are not commonly reported in treated cohorts.^[92] Concurrently, UV therapy promotes vitamin D synthesis, which exhibits photoprotective properties by repairing UV-induced DNA damage, mitigating oxidative stress, and modulating inflammation, potentially offsetting some carcinogenic and aging risks.^[93] Risk mitigation is evident in comparative long-term studies, where narrowband UVB (NB-UVB) demonstrates lower skin cancer incidence than broadband UVB (BB-UVB), with no significant elevation in melanoma or non-melanoma cancers observed in cohorts followed through 2023; however, a 2024 multi-center study reported elevated standardized incidence ratios (SIR 2.5 for basal cell carcinoma, 3.7 for squamous cell carcinoma, 4.0 for melanoma), though authors note limitations including short follow-up and potential confounders, calling for further confirmation.^[94]^[16] This reduced risk profile, attributed to NB-UVB's narrower spectrum and lower total energy delivery, supports its preference for minimizing cumulative hazards in extended therapy courses.^[16]

Contraindications and Precautions

Ultraviolet light therapy, including UVB and PUVA, has several absolute contraindications to prevent severe adverse outcomes. Photosensitive disorders such as systemic lupus erythematosus and porphyria are absolute contraindications due to the risk of exacerbated photosensitivity reactions and potential systemic complications from UV exposure.^[95]^[1] Active skin cancer, including non-melanoma types, prohibits therapy as UV light may promote tumor progression or metastasis.^[1] Pregnancy represents an absolute contraindication for PUVA therapy owing to teratogenic risks from psoralens, though narrowband UVB may be considered in select cases with caution.^[96]^[97] Relative contraindications require individualized risk-benefit assessment before initiating treatment. A history of melanoma or other skin cancers warrants careful evaluation, as UV exposure may elevate recurrence risk.^[1] Immunosuppressed patients, such as those with HIV or on immunosuppressive drugs, face heightened susceptibility to UV-induced damage and infections, making therapy relatively contraindicated unless benefits outweigh risks.^[95] Concomitant use of photosensitizing medications, including tetracyclines, thiazides, or retinoids, is a relative contraindication due to increased photosensitivity and burn potential.^[1]^[96] Precautions are essential for safe patient selection and administration. Individuals with Fitzpatrick skin type I (very fair skin that burns easily) require lower initial doses and close monitoring to minimize acute erythema risks.^[96] Elderly patients should undergo thorough evaluation for comorbidities and skin fragility, with adjusted protocols to avoid excessive exposure.^[1] In PUVA therapy, gonadal shielding is recommended for males to protect testicular function and fertility from scatter radiation.^[98] Informed consent must explicitly discuss potential long-term cancer risks, as referenced in safety guidelines.^[97] The American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) joint guidelines emphasize pre-treatment screening, including full skin exams, personal and family history of skin cancer, and review of photosensitizing medications, to identify at-risk patients.^[96] Follow-up biopsies are advised for those with suspicious lesions or high-risk profiles to ensure ongoing safety.^[97] These recommendations, updated through 2019 with ongoing relevance, guide dermatologists in optimizing patient eligibility.^[77]

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