New ways of delivering a well-tried treatment – two studies presented at the British Association of Dermatologists’ Annual Meeting 8-11 July 2013, Liverpool

A lot of time can be used up waiting at the hospital to have regular phototherapy sessions for skin disease. This is a treatment that is often used for common conditions such as psoriasis and eczema. Usually this treatment is given in hospital-based phototherapy units and because travel or regular attendance can be a problem, some people, for whom this would be an ideal approach, cannot get the treatment they need.

Two studies presented at the British Association of Dermatologists Annual Meeting will look at the pros and cons of providing phototherapy in alternative ways or in alternative settings that would help to address that need.

A group from NHS Tayside, who have provided a home ultraviolet B (UVB) phototherapy service for the past 15 years, looked at the feasibility of patients self-administering phototherapy in a hospital outpatient department (1). They underook a pilot project where a group of patients were given a two day training programme. In subsequent monitoring of these patients and comparing the outcomes to a group having the same therapy administered by nurses, similar results were found for efficacy and rate of adverse effects.

Most patients and staff viewed self-administration of phototherapy positively, although it was clear that this approach is only suitable for some patients. The indications from the pilot study suggested that it would be a safe and effective service that would require around 50 per cent less nurse input. The team are now looking at developing this further and hope that it will further increase access and availability of phototherapy for patients whislt freeing up nurse time to provide other patient services.

The other study, undertaken by a team based in Wales (at Cardiff University, Welsh Insitute of Dermatology, Cardiff, Aneurin Bevan Health Board, St Woolos Hospital, Newport) took the findings from the PLUTO study as their starting point . This study found that home phototherapy for psoriasis is safe and as effective as phototherapy administed in hospital, in their own study they aimed to find out what local knowledge and attitudes to home phototherapy might be.

Home phototherapy is widely available in the Netherlands, Germany and the United States and the health economic analysis from the PLUTO study showed that it was cost neutral compared with hospital phototherapy. Using semi-structured interviews the researchers found that 75 per cent of consultants, 100 per cent of registrars, 100 per cent of nurse specialists and 78 per cent of patients thought that home phototherapy was a good idea.

Dermatology professionals gave the main reason for this as ‘less waste of patient time and less travelling’ and the main perceived barrier was ‘cost’. For patients the main reason for supporting home phototherapy was similar being ‘convenience’, ‘less time travelling’ and ‘transport logistics’.

Dr Salako, one of the team said:
“Although there was scepticism about home phototherapy from some of the dermatology professionals we think our findings, in this local sample, are widely representative and they suggest that more should be done to make the case for home phototherapy in the UK.”

-Ends-
Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

Study details:
1. Self-administration of hospital-based narrowband UVB (TL-01) phototherapy: a feasibility study in an
outpatient setting
S. Yule,1 S. Sanyal,1 S. Ibbotson,2 H. Moseley1 and R.S. Dawe1
1NHS Tayside, Dundee, U.K., 2University of Dundee, Dundee, U.K.

2. Evaluation of patients’ and healthcare professionals’ knowledge and views about home phototherapy
S. Lumley,1 K. Salako2 and Alex V. Anstey3
1School of Medicine, Cardiff University, Cardiff, U.K., 2Welsh Institute of Dermatology, Cardiff, U.K. and 3Aneurin Bevan Health Board, Academic Dermatology, St. Woolos Hospital, Newport, U.K.

ABSTRACTS:

1. Self-administration of hospital-based narrowband UVB (TL-01) phototherapy: a feasibility study in an outpatient setting
S. Yule,1 S. Sanyal,1 S. Ibbotson,2 H. Moseley1 and R.S. Dawe1
1NHS Tayside, Dundee, U.K., 2University of Dundee, Dundee, U.K.

Narrowband (TL01 lamp) ultraviolet B (UVB) is used to treat a variety of dermatoses, including the common conditions of psoriasis and atopic eczema. This treatment is most often given in hospital-based phototherapy units; difficulty in
attending such units regularly means that some people, for whom this would otherwise be an ideal approach, cannot easily attend for this effective and safe treatment. There are a variety of approaches to increase availability of this treatment, including supervised home phototherapy. Some patients cannot easily attend hospital phototherapy units when they are open. For some of these, home phototherapy is an appropriate option; for others it is not practicable (for example, some may have inadequate space in their homes for home phototherapy equipment). Self-administration of UVB phototherapy by outpatients might be appropriate for some. We wanted to assess the feasibility of outpatients self-administering UVB phototherapy in a hospital outpatient setting. A pilot project was commenced in November 2011. A total of 27 patients with psoriasis (n = 20) and atopic eczema (n = 7), (17 women, mean age 32 years, range 17–56) were recruited.
Our home phototherapy training programme was adapted. Patients underwent a 2-day training programme, which
included a minimal erythema dose (MED) test and supervised treatment. Patient and staff questionnaires were used to gather feedback. Treatment data were collected for 26 patients. The mean number of exposures was 23 (SD 9), and the mean cumulative dose was 15 J cm_2 (SD 11). Efficacy and rate of adverse effects were found to be similar to those of patients having nurse-administered treatment. Self–administration of treatment by outpatients required ~50% less nursing input than for conventional nurse-administered phototherapy. Most patients and staff viewed this model of care positively. Early indications suggest that this is a safe and effective service development that provides a patient-centred approach to care.
Having a group of patients trained to self–administer treatment empowers them to take a more active role in their treatment as part of their chronic disease management, and could free up nursing time to provide other patient services. We are planning further to develop this service by piloting the use of a dedicated unit on our dermatology ward for self-administration of treatment by outpatients. This service development would further increase access and availability of phototherapy for patients.

2. Evaluation of patients’ and healthcare professionals’ knowledge and views about home phototherapy
S. Lumley,1 K. Salako2 and Alex V. Anstey3
1School of Medicine, Cardiff University, Cardiff, U.K., 2Welsh Institute of Dermatology, Cardiff, U.K. and 3Aneurin Bevan Health Board, Academic Dermatology, St. Woolos Hospital, Newport, U.K.

The PLUTO study (Koek MB, Buskens E, van Weelden H et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009; 338: 1542) showed that home phototherapy for psoriasis is as safe and effective as phototherapy administered in hospital. Furthermore, health economic analysis from this study showed that home phototherapy is cost-neutral compared with hospital phototherapy. Home phototherapy is now widely available in the Netherlands, Germany and the United States, but provision remains limited in the U.K. Our aim was to explore local knowledge and attitudes about home phototherapy to better understand potential barriers to the introduction of home phototherapy. Semi-structured interviews were carried out on a cross-sectional sample of 18 patients with psoriasis and 18 dermatology healthcare professionals. Awareness by dermatology professionals of the PLUTO study was as follows: 75% of consultants; 57% of registrars; 29% of dermatology specialist nurses. However, just 50% of the dermatology professionals were able to state the conclusions or take-home message from this study. Awareness of the 1998 BAD guidelines on home phototherapy was as follows: 25% of consultants; 57% of registrars; 43% of specialist nurses. When asked for their views on whether or not home phototherapy was a good idea, the rate of positive responses was: 75% of consultants; 100% of registrars; 100% of nurse specialists. When asked to explain why it was a good idea the main reason cited by 83% was ‘less waste of patient time and less travelling’. ‘Cost’ was the main perceived barrier preventing the introduction of home phototherapy on the NHS, cited as follows: 75% of consultants; 86% of registrars; 100% of nurses. Of patients, 78%
preferred the idea of home phototherapy for reasons such as ‘convenience’, ‘less time spent travelling’ and ‘transport logistics’.
In summary, the 18 dermatology professionals had a generally poor understanding of home UVB. Furthermore,
scepticism about home phototherapy was apparent in some. Patients and dermatology nurses were the most positive about the concept of home phototherapy. If our findings in this local sample are widely representative they suggest that more should now be done to make the case for home phototherapy in the U.K. Wider provision of home phototherapy would improve patient choice, widen access to phototherapy and reduce the burden of treatment for our patients. Research is now needed to determine how this innovative model for phototherapy can be integrated into existing frameworks of care.

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.