Phototherapy in Children

1. Phototherapy in Children Kathryn Thomson

3. Why are Children Different? • Not just small adults • height • Body Surface Area:mass ratio • psychological differences: understanding, anxiety, compliance, needs, peer response, stigma • long term impact- longer potential “treatment life” • extra people involved: parents/ carers • response to treatment • smaller treatment numbers therefore data not so available • data needs to be treated with caution as children often more severe than adults before phototherapy is considered

4. review of the literature • efficacy of phototherapy in different conditions • risks • published experience from different units • ideal requirements • tips on managing phototherapy in children

5. Phototherapy for children with Psoriasis • psoriasis estimated at affecting 0.75% population under 18 years • significant impact on quality of life • most studies look at NB-UVB with a few looking at PUVA and BB-UVB

6. Psoriasis Studies • Parlovsky et al JEADV 2011 • 88 patients; mean age 12 years (8-16) • 92% improved >75% or cleared • BUT treatment course 3.1 +/- 2.3 months • Ersoy-Evan et al -Paediatric Dermatology 2008 • 28 patients; mean age 12years+/- 2.5 • 92.9% clear or minimal residual disease (mrd) • mean treatment number= 16 for guttate, 36 for large plaque • Tan et al- Australas J Dermatology 2010 • 38 patients; mean age 11 (2.6-15.9)years • mean treatment number 27.8 (range 4-76) • 90% patients reach >75% reduction or clear

7. Atopic Eczema • Leeds study 2009 • retrospective database review over 6 years • 50 children with eczema had 10 or more treatments • clear or mrd in 40%, good imp in 23%, mod imp in 26% • children with higher MED more likely to clear • Darne et al BJD 2014 (Newcastle) • prospective study • SASSAD/ percentage involvement/ QoL scores comparing 29 children (age 3-16) with 26 controls (suitable for treatment but opted out) • 61% cw 6% reduction in SASSAD • 11% cw 36% percentage area • significant reduction in QoL scores • maintained at 6 months

8. eczema (continued) • Glasgow group Jury et al CED 2006 • median treatments 24 (range 3-46) • 68% achieved mrd, 16% no better cautions in eczema patients; increased risk of cataracts (consider ophthalmology review) reactivation of herpes simplex

9. Vitiligo • Ersoy-Evans et al 2008 • 26 patients • 9 treated with TLO1, 8 with PUVA, 9 with topical meladinine and UVA • 57% patient achieved 50% repigmentation with PUVA; 50% with TLO1 • only 2 of 9 with maladinine • median treatment number= 24.5 (range 17-106) for PUVA and 14 (9-107) for TLO1

10. Vitiligo (continued) • Grimes et al Paediatric Dermatology 1986 • children seem to have a better response to PUVA than adults • response probably variable • Percivalle et al Paed Derm 2012 • TLO1 in 28 children twice weekly (duration 10+/-3.4 months • 14% excellent response, 28.6% good response, 25% moderate response, 28.6 mild • 3.5% no response • no side effects other than erythema • recommend stopping at 6 months if no better

11. Photodermatoses including PLE • large patient series report good levels of protection with UVA, UVB and PUVA • NBUVB probably treatment of choice as has shown in adults to be as effective as PUVA

12. Why use Phototherapy? • Some children do not get adequate response from topical treatments • active skin disease has large effect on daily life of children and families • Phototherapy often preferable to oral immunosuppressants • Data suggests that it is a useful treatment • BUT • Long term potential side effects still uncertain to treat with caution • requires commitment from patient and families

13. What Do we need to consider when treating Children? • Social aspects • phototherapy course may take a number of weeks • patient may need time off school • parent/ carer may need time off work • treatment may need to be explained to the school

14. Patient Anxiety • phototherapy machines can be scary for children • they may feel hot and airless careful explanation to parent and child clear child friendly information sheets early introduction to machine and staff allow extra time at assessment clinic allow to stand in machine with door open and clothes on before treatment starts allow to try on the goggles and make it fun treatment can be split if longer session if needed parent can go in machine (covered up) consider audio tapes for longer sessions

15. Parental Counselling • explain how machine works • explain need for goggles/ visor • reduce ambient sun exposure (sun screen/ hats, avoid hottest part of the day etc) • Include child in all decision making. If possible get both child and parent to sign the consent form • Use reward (star) cards/ stickers/ certificate on completion (age appropriate)

16. Practical Considerations • Tubes get weaker towards the bottom. As young children are smaller they should stand on a platform for treatment • As for most paediatric patients ensure a child appropriate waiting area- books, toys etc • If possible a nurse with paediatric experience should be available • Children get bored quickly – try to be on time and get parents to bring things to entertain them • If using PUVA, oral not ideal as children less likely to be compliant with glasses and parents wont always be with them. • If goggles needed allow patient to choose them

18. Summary • All types of phototherapy have been shown to be effective in children. • If planned well anxieties can be managed and may enable the avoidance of oral immunosuppressants