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British Photodermatology Group Position Statements

Below you will find BPG's position statements on Ultraviolet (UV) emissions and Compact Fluorescent Lights, Phototherapy for skin disease, Photodynamic Therapy, and Sunbeds.

Ultraviolet (UV) emissions and Compact Fluorescent Lights

 

Background

Legislation in Europe and United States has led to the phasing out of incandescent light bulbs by 2012 and 2014, respectively.  Similar legislation has been passed in several other countries.  The principal driver is to improve lighting efficiency in order to reduce carbon dioxide emissions. 

Incandescent (tungsten) bulbs have been replaced largely by compact fluorescent lamps (CFLs); those with a bare tube are generally termed “single envelope” CFLs and those in which the tube is enclosed in a glass or polycarbonate cover are designated “double envelope” bulbs. 

The UV spectrum is usually divided according to wavelength into UVA (315-400nm) which is closest to visible light, UVB (280-315nm) and UVC (100-280nm). The UV emission from each light source is very different.  Although the traditional tungsten lamp emits measureable amounts of UVA, the UVB levels are extremely low and the heat from this lamp limits exposure at close distance.  In contrast, the CFL emissions are widely variable, depending on the individual lamp.  The single envelope CFL in particular has been shown to emit significant quantities of UVB in some cases and also measureable amounts of UVC.  Light emitting diodes (LEDs) have virtually no UV emission.

There are many skin conditions caused or exacerbated by exposure to UV radiation.  These include polymorphic light eruption, chronic actinic dermatitis, solar urticaria, xeroderma pigmentosum and lupus erythematosus.  Investigations carried out on photosensitive patients have shown that exposure to single envelope CFL can induce an erythematous reaction in photosensitive individuals.  The number of reactions was much reduced when double envelope CFLs were used and, for all UV-sensitive patients, responses to exposure from the LED were negative.  Currently, there is no scheme in place to indicate to photosensitive patients or to healthcare professionals which lamps are safe to use.  Some patients, including those with lupus and some other connective tissue diseases, describe a variety of symptoms both in the skin and systemically. There is currently a lack of a research evidence base in this area which makes it difficult to comment or make a judgement on this issue from a medical and scientific viewpoint. Further research in this area is required.

The exposure to UV radiation is also recognised as a risk factor for skin cancer.  However, any change in personal risk as a result of exposure to UV from CFLs is considered to be very small and much less than the risk from UV exposure outdoors.

  • Occupational exposure to UV radiation within the EU is subject to the Artificial Optical Radiation Directive which specifies exposure limit values for workers and also obliges the employer to consider any effects concerning safety of staff belonging to particularly sensitive groups. It should also be noted that the Health Protection Agency has issued precautionary advice to the public to maintain a distance of at least 30cm from a single envelope CFL.

Recommendations

  • CFLs present a low level of risk to the skin of individuals of normal sensitivity but are potentially harmful to photosensitive patients.
  • Some single envelope CFLs emit detectable levels of UVA, UVB and UVC that may provoke a skin reaction in photosensitive individuals.
  • Double envelope CFLs emit lower levels of UVB and UVC and are therefore a safer alternative for UV-sensitive individuals.
  • LEDs have minimal UV emissions and are therefore a safer alternative to CFLs for UV-sensitive individuals.
  • We advocate the introduction of a lamp classification scheme suitable for UV-sensitive individuals.

References

1          Eadie E, Ferguson J, Moseley H. A preliminary investigation into the effect of exposure of photosensitive individuals to light from compact fluorescent lamps. British Journal of Dermatology 2009; 160: 659-64.

2          Fenton L, Ferguson J, Moseley H. Analysis of energy saving lamps for use by photosensitive individuals. Photochemistry and Photobiological Sciences 2012; 11.

3          Moseley H, Ferguson J. The risk to normal and photosensitive individuals from exposure to light from compact fluorescent lamps. Photodermatology, Photoimmunology & Photomedicine 2011; 27: 131-7.

4          Khazova M, O’Hagan JB. Optical radiation emissions from compact fluorescent lamps. Radiation Protection Dosimetry 2008; 131: 521-5.

5          Nuzum-Klein A, Sontheimer R. Ultraviolet light output of compact fluorescent lamps: comparison to conventional incandescent and halogen residential lighting sources. Lupus 2009; 18: 556-60.

6          Sayre R, Dowdy J, Poh-Fitzpatrick M. Dermatolgical risk of indoor ultraviolet exposure from contemporary lighting sources. Photochemistry and Photobiology 2004; 80: 47-51.

7          Scientific Committee on Emerging and Newly Identified Health Risks.  European Commission, Directorate-General for Health & Consumers.  Health effects of artificial light.  Opinion adopted on 19th March 2012.  Available at: http://ec.europa.eu/health/scientific_committees/emerging/opinions/index_en.htm

 

PRODUCED JANUARY 2013

REVIEW DATE DECEMBER 2015

British Photodermatology Group  www.bpg.org.uk

The British Photodermatology Group (BPG) is a special interest society of the British Association of Dermatologists, and acts as a forum of communication for all those with an interest in photodermatology.

 

 

 

Phototherapy for skin disease

Background

Phototherapy is the use of ultraviolet or visible light to treat disease. The main forms of phototherapy used for skin diseases are ultraviolet B (usually using lamps producing narrowband ultraviolet B) and psoralen plus ultraviolet A (PUVA). A specialised form of phototherapy called ultraviolet A1 is also used, although not widely.

Various skin conditions can be treated with phototherapy (including psoriasis [1,2], atopic eczema, chronic urticaria [3] and vitiligo); generalised itch (such as the widespread itch that is caused by some severe kidney problems) can be helped [4]; T cell lymphoma of the skin typically responds well to ultraviolet B [5] and to PUVA [6]. Phototherapy can also be used  to build up tolerance in those with various sunlight sensitivity skin disorders [7]. Phototherapy is not ‘artificial sunlight’. Conditions that do not benefit from sunlight exposure, and even conditions triggered or made worse by sunlight exposure, often benefit from the correct choice of phototherapy [8,9].

For many conditions both narrowband ultraviolet B and PUVA are treatment options. As ultraviolet B is simpler and the risks of side effects are less, it is used more frequently. PUVA is a good option for some conditions that do not respond to ultraviolet B and also for people with conditions which usually respond well to ultraviolet B but who have not responded adequately to this therapy. PUVA and ultraviolet B work in different ways and PUVA can work well when ultraviolet B has not done so.

Usually, phototherapy with ultraviolet B is given three-times a week and twice a week for PUVA. Ultraviolet B phototherapy involves standing in an ultraviolet B treatment cabinet; PUVA involves taking psoralen tablets or soaking in a psoralen solution before standing in an ultraviolet A treatment cabinet. The number of treatments needed for a course of phototherapy varies across the different conditions and from person to person, but a typical course is between 15 and 30 treatments.

As with all effective treatments there are possible side effects with the phototherapies. The commonest unwanted effects are sunburn-like reactions (skin redness) and tanning.  With PUVA, there is an increased risk of skin cancer which is related to the cumulative lifetime number of treatments. A large Swedish study found that one in 18 patients treated with more than 180 whole-body PUVA treatments developed a squamous cell skin cancer [10], confirming an increased skin cancer risk with PUVA that has also been shown in other studies [11].  The risks of alternative treatments, such as the risks of internal side effects as well as of skin cancer with immunosuppressant tablet treatments, need to be considered when deciding what this small increased risk of skin cancer, after a high cumulative exposure to PUVA, means. Although from what we know about ultraviolet in general, and from studies on cells and animals, it seems likely there should also be some increased skin cancer risk with ultraviolet B, to date no increased risk of skin cancer in people treated with narrowband ultraviolet B has been found [12].

Some people who could benefit from phototherapy find it difficult to attend for this treatment as they live too far away from the hospital or the opening times of a local unit do not fit in with their work and home commitments. Most dermatology services try to make phototherapy available through a ‘hub and spoke’ model with ultraviolet B and PUVA available in a central department as well as in smaller hospitals. In many places, efforts are also being made to extend unit opening times. Another complementary way of extending availability of phototherapy is to provide a hospital supervised home phototherapy service. Supervised home phototherapy has been shown to be as effective and safe as hospital phototherapy as well as being cost effective, but is not available in all regions. [13,14]

The phototherapies should be given in units participating in a clinical governance scheme, such as the national managed clinical network for phototherapy through which all phototherapy in Scotland is delivered (http://www.photonet.scot.nhs.uk/). This ensures the treatments are given as effectively and safely as possible, with ongoing audit to identify any problems. Such systems help to ensure that the correct phototherapies are used for the correct conditions. Prescription of courses of phototherapy must be by a dermatologist knowledgeable about these treatments and about any possible alternative treatments.

There are ongoing efforts to develop new phototherapy treatments as well as to work out how best (most safely and most effectively) to use the phototherapy treatments already available.

Recommendations

Phototherapy (at a minimum narrowband ultraviolet B and PUVA) should be available to all for whom a phototherapy treatment is indicated.

If ultraviolet B phototherapy has been inadequate, PUVA should be considered as a next line approach which is usually appropriate before systemic therapies.

The skin cancer risks of PUVA are important and should be considered when deciding on appropriate treatment for an individual, but these risks should be considered in context, including the skin cancer, and other, risks of any alternative therapies.

Phototherapy should be delivered in a clinical governance system, and following, at a minimum, the recommendations of the British Association of Dermatologists Phototherapy Working Party Report (2012) (http://www.bad.org.uk/Portals/_Bad/Clinical%20Services/BAD%20Working%20Party%20Report%20on%20Phototherapy%20Services%202011v8%20final%20draft%20Logo.pdf).

Measures should be taken to make access to phototherapy as equitable as possible throughout the UK..Such measures to consider include ensuring adequate phototherapy units (in many areas a ‘hub and spoke’ model is appropriate), opening hours appropriate to the population served and hospital phototherapy unit supervised home phototherapy. Unsupervised treatment with phototherapy at home is not recommended).

 

References:

1          Sivanesan SP, Gattu S, Hong J, Chavez-Frazier A, Bandow GD, Malick F, Kricorian G, Koo J. Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks. J Am Acad Dermatol 2009; 61: 793-8.

2          Dawe RS. A quantitative review of studies comparing the efficacy of narrow-band and broad-band ultraviolet B for psoriasis. Br J Dermatol 2003; 149: 669-72.

3          Engin B, Ozdemir M, Balevi A, Mevlitoglu I. Treatment of chronic urticaria with narrowband ultraviolet B phototherapy: a randomized controlled trial. Acta Derm Venereol 2008; 88: 247-51.

4          Gilchrest BA, Rowe JW, Brown RS, Steinman TI, Arndt KA. Relief of uremic pruritus with ultraviolet phototherapy. N Engl J Med 1977; 297: 136-8.

5          Clark C, Dawe RS, Evans AT, Lowe G, Ferguson J. Narrowband TL-01 phototherapy for patch-stage mycosis fungoides. Arch Dermatol 2000; 136: 748-52.

6          Stadler R, Otte HG, Luger T, Henz BM, Kuhl P, Zwingers T, Sterry W. Prospective randomized multicenter clinical trial on the use of interferon -2a plus acitretin versus interferon -2a plus PUVA in patients with cutaneous T-cell lymphoma stages I and II. Blood 1998; 92: 3578-81.

7          Collins P, FergusonJ. Narrow-band UVB (TL-01) phototherapy: an effective preventative treatment for the photodermatoses. Br J Dermatol 1995; 132: 956-63.

8          Boer J, Schothorst AA, Suurmond D. Ultraviolet B phototherapy for psoriasis in sunlight-responsive patients. Lancet 1979; 1: 773.

9          Dawe RS, Ferguson J. History of psoriasis response to sunlight does not predict outcome of UVB phototherapy. Clin Exp Dermatol 2004; 29: 413-4.

10        Lindelof B, Sigurgeirsson B, Tegner E, Larko O, Johannesson A, Berne B, Ljunggren B, Andersson T, Molin L, Nylander-Lundqvist E, Emtestam L. PUVA and cancer risk: the Swedish follow-up study. Br J Dermatol 1999; 141: 108-12.

11        Stern RS, Liebman EJ, Vakeva L. Oral psoralen and ultraviolet-A light (PUVA) treatment of psoriasis and persistent risk of nonmelanoma skin cancer. PUVA Follow-up Study. J Natl Cancer Inst 1998; 90: 1278-84.

12        Hearn RM, Kerr AC, Rahim KF, Ferguson J, Dawe RS. Incidence of skin cancers in 3867 patients treated with narrow-band ultraviolet B phototherapy. Br J Dermatol 2008; 159: 931-5.

13        Koek MB, Buskens E, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009; 338: b1542.

14        Koek MB, Sigurdsson V, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Buskens E. Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomised controlled trial (PLUTO study). BMJ 2010; 340: c1490

PRODUCED JANUARY 2013

REVIEW DATE DECEMBER 2015

British Photodermatology Group  www.bpg.org.uk

 

The British Photodermatology Group (BPG) is a special interest society of the British Association of Dermatologists, and acts as a forum of communication for all those with an interest in photodermatology.

 

 

 

Photodynamic Therapy

Background

Topical photodynamic therapy (PDT) is widely used in Dermatology and involves photoactivation of a tissue-localised photosensitiser, with resulting photodynamic effect. To date, mainly porphyrin pro-drugs have been used. Topical PDT is highly effective for superficial non-melanoma skin cancer (NMSC) and is at least as effective as cryotherapy and imiquimod for actinic keratosis (AK), 5-fluorouracil and cryotherapy for Bowen’s disease (BD), and cryotherapy and surgery for superficial basal cell carcinoma (SBCC).  Cosmetic outcome and patient preference is superior for PDT in comparative studies.  Long-term recurrence rates are approximately 20-25% by three to five years which is consistent with other non-surgical therapies.  British and European guidelines summarise the evidence base for topical PDT1-3.

PDT is an important and advantageous therapeutic option for patients with multiple or large lesions and for field change and specific body sites where healing is compromised, such as the lower leg.  It can be effectively used in immunosuppressed patients. For nodular BCC, topical PDT is inferior to surgery with follow-up to five years and topical PDT would not be the treatment of choice for nodular BCC unless surgery was contraindicated.  Topical PDT is not recommended for invasive squamous cell carcinoma, malignant melanoma, other heavily pigmented tumours or subcutaneous metastases. 

Topical PDT is generally well tolerated, although pain during irradiation can occur. Pain relief can usually be achieved by simple measures, such as cooling and reduction of irradiance of light delivery. The latter is being explored by use of very low irradiance portable or daylight PDT regimes. Nerve blockade is only occasionally required.

Topical PDT was assessed by NICE (Interventional procedures guidance 155 (Feb 2006); Medical Technologies Guidance MTG6 (July 2011)).  Topical PDT was also included in a systematic review of PDT in Oncology4and a review by the Department of Health (report in preparation). 

In summary, topical PDT should be widely available in dermatology, and accessible to all involved in the management of patients via skin cancer pathways.  Its main use should be for superficial AK, BD and SBCC and it is advantageous for patients with large and multiple lesions, field carcinogenesis, and difficult treatment sites such as the lower leg.  Treatment outcomes should be recorded by local governance mechanisms. 

 

Recommendations

·         Topical PDT should be accessible to all dermatology departments and particularly for those involved in skin cancer management.

·         Topical PDT should be considered for patients with a diagnosis of superficial basal cell carcinoma, Bowen’s disease or actinic keratosis.

·         Topical PDT should be considered as treatment of choice for Bowen’s disease on the lower leg because of the proven reduction in risk of complications at this site.

·         Topical PDT is particularly advantageous and should be considered as first-line treatment for patients with large, multiple, low risk lesions and field change carcinogenesis, including in immunosuppressed patients.

·         Mechanisms of governance are desirable and should be encouraged in order to monitor treatment delivery and outcomes (the principles of phototherapy guidelines are allied and may be a useful resource to adapt in this context).

References

1          Morton CA, Brown SB, Collins Set al. Guidelines for topical photodynamic therapy: report of a workshop of the British Photodermatology Group. Br J Dermatol 2002; 146: 552-67.

2          Morton CA, McKenna KE, Rhodes LEet al. Guidelines for topical photodynamic therapy: update. Br J Dermatol 2008; 159: 1245-66.

3          Braathen LR, Szeimies RM, Basset-sequin Net al. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus. J Am Acad Dermatol 2007; 56: 125-43.

4          Fayter D, Corbett M, Heirs Met al. A systematic review of photodynamic therapy in the treatment of pre-cancerous skin conditions, Barrett's oesophagus and cancers of the bilary tract, brain, head and neck, lung, oesophagus and skin. Health Technol Assess 2010; 14: No.37.

 

PRODUCED JANUARY 2013

REVIEW DATE DECEMBER 2015

British Photodermatology Group  www.bpg.org.uk

The British Photodermatology Group (BPG) is a special interest society of the British Association of Dermatologists, and acts as a forum of communication for all those with an interest in photodermatology.

 

 

 

Sunbeds

Introduction

The availability and use of commercial ultraviolet-A (UVA) sunbeds has increased greatly in recent years. At the same time the intensity of UV emitted by these sunbeds has also increased such that their skin cancer risks are often equivalent to Mediterranean summer sunlight1. The enlarged sunbed market includes many outlets without supervisory staff, where customers choose the frequency and duration of exposures without clear advice or health warnings.

There is strong evidence that use of sunbeds increases the risk of skin cancers, including malignant melanoma2. For those who start using sunbeds before the age of 35 years the relative risk of malignant melanoma almost doubles.

Now all countries of the UK have introduced legislation controlling the use of commercial sunbeds. All European, and most International bodies concerned with advice on cancer or radiation protection have issued position statements or other guidance discouraging use of UV devices for cosmetic tanning and recommending restrictions on their use by under 18 year olds. The World Health Organisation classifies sunbeds as a “Group 1 Carcinogen”2-8.

Recommendations:

The British Photodermatology Group supports the provisions of the UK Sunbed Acts as good first steps towards a policy to minimise the risks of sunbed use.  These should be enforced by regulation of sunbed operators and inspection of premises.

In view of the statements, reports and advice of many National and International agencies on the use of sunbeds, and in light of the strong evidence of harm from the use of sunbeds for cosmetic tanning, the British Photodermatology Group make the following recommendations:

  • The use of UV equipment for cosmetic tanning should be strongly discouraged.

  • In commercial premises sunbed use should be banned for under-18s, as already enacted in all the countries of the UK.

  • Strong public information programmes should emphasise the risks of sunbeds, especially to children and young adults.

  • Advertising by the sunbed industry should be carefully scrutinised.

  • Any claims of health benefits from sunbed use should be banned.

Sunbeds should never be used by these groups::
Under 18 years of age
Those with fair/freckly skin that does not normally tan with sun exposure
Those with large number of moles
Those with a history of skin cancer;
Those with abnormal sensitivity to the sun either due to photosensitive skin diseases (sun allergies) or medication

As part of the Registration of owners/operators of sunbed premises and sunbed manufacturers:
Claims of health benefits for sunbeds must not be made.

All sunbeds should be limited to types I, II or III as defined by the IEC Standard (BS EN 60335-2-27: 2003)9. Use of UV tubes that exceed these limits should be banned.

UV goggles must be provided to clients.

All premises should be staffed by trained personnel.

Clearly visible information on minimising the risks from sunbeds and appropriate health warnings should be provided to clients prior to tanning exposure.

References:

1          Oliver H, Ferguson J, Moseley H. Quantitative risk assessment of sunbeds: impact of new high power lamps. British Journal of Dermatology August 2007; 157: 350-6.

2          IARC. International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and otheer skin cancers: A systematic review. Int J Cancer 2007; 120: 1116-22.

3          WHO. Artificial Tanning Sunbeds Risks and Guidance. In. Geneva: World Health Organisation. 2003.

4          CR-UK. Cancer Research UK Policy Statement Sunbeds. In: Cancer Research UK. 2009.

5          ICNIRP. Health Issues of Ultraviolet Tanning Appliances Use for Cosmetic Purposes. International Commission on Non-Ionising Radiation Protection. Health Physics 2003; 84: 119-27.

6          COMARE. Committee on Medical Aspects of Radiation in the Environment (COMARE) Report 13: The Health Effects and Risks Arising from Exposure to Ultraviolet Radiation from Artificial Tanning Devices. In: Health Protection Agency. 2009.

7          SCCP. EU Scientific Committee on Consumer Products (SCCP) Preliminary opinion on: Biological Effects of Ultraviolet Radiation Relevant to Health with Particular Reference to Sun Beds for Cosmetic Purposes. In: EU SCCP. 2005; SCCP/0949/05.

8          CIEH. Chartered Institute of Environmental Health Policy Briefing Note - Sunbeds. In: Chartered Institute of Environmental Health. 2010.

9          IEC. Safety of Household and Similar Appliances. In: Part 2: Particular requirements for appliances for skin exposure to ultraviolet and infrared radiation., Vol. 335. Geneva: International Electrotechnical Commission. 1995; 2-27.

PRODUCED JANUARY 2013

REVIEW DATE DECEMBER 2015

British Photodermatology Group  www.bpg.org.uk

The British Photodermatology Group (BPG) is a special interest society of the British Association of Dermatologists, and acts as a forum of communication for all those with an interest in photodermatology.

 

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