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Narrow-band ultraviolet B phototherapy versus broad-band ultraviolet B or psoralen-ultraviolet A photochemotherapy for psoriasis

  1. Xiaomei Chen1,†,
  2. Ming Yang2,‡,
  3. Yan Cheng1,
  4. Guan J Liu3,
  5. Min Zhang1,*

Editorial Group: Cochrane Skin Group

Published Online: 23 OCT 2013

Assessed as up-to-date: 8 AUG 2013

DOI: 10.1002/14651858.CD009481.pub2


How to Cite

Chen X, Yang M, Cheng Y, Liu GJ, Zhang M. Narrow-band ultraviolet B phototherapy versus broad-band ultraviolet B or psoralen-ultraviolet A photochemotherapy for psoriasis. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD009481. DOI: 10.1002/14651858.CD009481.pub2.

Author Information

  1. 1

    West China Hospital, Sichuan University, Department of Dermatology & Venereology, Chengdu, Sichuan, China

  2. 2

    West China Hospital, Sichuan University, Center of Geriatrics and Gerontology, Chengdu, Sichuan, China

  3. 3

    West China Hospital, Sichuan University, Chinese Cochrane Centre, Chinese Evidence-Based Medicine Centre, Chengdu, Sichuan, China

  1. ❖ Joint first author

  2. ✢ Joint first author

*Min Zhang, Department of Dermatology & Venereology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China. hxlily@163.com. lily666@medmail.com.cn.

Publication History

  1. Publication Status: New
  2. Published Online: 23 OCT 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

 
Summary of findings for the main comparison. NB-UVB compared with oral PUVA for chronic plaque psoriasis

NB-UVB compared with oral PUVA for chronic plaque psoriasis

Patient or population: People with chronic plaque psoriasis
Settings: -
Intervention: NB-UVB
Comparison: Oral PUVA

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Oral PUVANB-UVB

Participant-rated global improvementStudy populationNot estimable0
(0)
See commentNo included RCT addressed this outcome

See commentSee comment

Moderate


Percentage of participants reaching PASI 75720 per 1000655 per 1000
(454 to 950)
RR 0.91
(0.63 to 1.32)
51
(1 study)
⊕⊕⊝⊝
low¹, ²
This is the result of ITT analysis

Withdrawal due to side-effects32 per 100050 per 1000

(7 to 82)
RR 0.71
(0.20 to 2.54)
247
(3 study)
⊕⊕⊝⊝
low³
This is the result of ITT analysis

Clearance rateStudy populationNot estimable0
(0)
See commentThe results of 3 small RCTs are contradictory. Because of the significant statistical heterogeneity, the data were not pooled

See commentSee comment

Moderate


*Comment: The basis for the assumed risk (e.g. the median control group risk across studies) is provided in the footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 ¹ The study was of small sample size.
² The study was at high risk of bias.
³ All of the 3 studies were of small sample size and at high risk of bias, and the result was based on less than 300 participants.

 Summary of findings 2 NB-UVB compared with bath PUVA for chronic plaque psoriasis

 Summary of findings 3 NB-UVB compared with topical PUVA for palmoplantar psoriasis

 Summary of findings 4 NB-UVB plus retinoid compared with PUVA plus retinoid for chronic plaque or guttate psoriasis

 Summary of findings 5 NB-UVB compared with selective BB-UVB for chronic plaque psoriasis

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Please note that unfamiliar terms and abbreviations are listed in  Table 1 ('Glossary of some important terms and abbreviations used').

 

Description of the condition

 

Description and epidemiology

Psoriasis is a common, chronic inflammatory skin disease, with an estimated global prevalence ranging from 0.5% to 4.6% (Lebwohl 2003). The typical lesions of psoriasis include well-demarcated red plaques, with variable degrees of silvery thickening, and surface scale, particularly on the scalp, extensor aspects (backs of the elbows, fronts of the knees) of the limbs, and the trunk. Psoriatic arthritis, pustular psoriasis (a subtype of psoriasis with lesions containing purulent materials), or erythrodermic psoriasis (a subtype of psoriasis that affects nearly all body sites) may also be present. Among the various subtypes, psoriasis vulgaris is the most common form and accounts for more than 80% of psoriasis cases (Lebwohl 2003). The characteristic pathological changes of psoriasis present with hyperkeratosis (thickening of the stratum corneum, which is usually associated with an abnormality of the keratin and an increase of the granular layer), hyperplasia (increase in the number of cells) of the epidermis, inflammatory cell infiltration into the dermis and epidermis, and dilatation of dermal capillaries (dilated small blood vessels in the dermis). The diagnosis of psoriasis is mainly based on clinical features, and pathological changes are usually helpful to distinguish psoriasis from other diseases with a similar appearance.

 

Cause

The exact cause of psoriasis remains unclear. However, psoriasis appears to be a disorder of immune function (specifically involving the T set of lymphocytes), which causes an accelerated rate of cell turnover in the epidermal layer of the skin (Griffiths 1996). People seem to have a strong genetic predisposition to develop the condition. Certain medications (such as lithium, beta blockers, antimalarial drugs, and nonsteroidal anti-inflammatory drugs) and infections are thought to be possible triggers.

 

Impact

Although psoriasis is rarely life-threatening, the effect on a person's quality of life (QOL) can be profound, with a damaging effect on their self-esteem, due to the long-term nature of the disease, the persistent itching or pain of the skin, and the stigmatising effect of a disfiguring condition (De Korte 2004). It also seems to be associated with a significantly increased risk of cardiovascular disease (Gelfand 2006) and a variety of malignant diseases (Boffetta 2001; Gelfand 2003; Hannuksela-Svahn 2000).

 

Description of the intervention

Management of psoriasis should depend upon a number of factors: These include the severity of the disease, associated diseases (comorbidities), education about the chronic nature of the disease, and realistic expectations about the effect of treatments, as well as the use of medication. Complete clearance of psoriasis may be unrealistic, so the main aim of treatment is to reduce disease activity with minimal side-effects.

Interventions include topical therapy, ultraviolet light (phototherapy), systemic agents, and biological treatments. Those mildly affected can generally be treated adequately with topical medication, but 10% to 20% of those with moderate-to-severe psoriasis often depend upon phototherapy, systemic treatment, or combination therapy to achieve and sustain disease remission (Jensen 2010).

Phototherapy is an essential therapeutic option for people with psoriasis and has been used for more than 75 years. The most commonly used types of phototherapy are photochemotherapy using psoralen ultraviolet A (PUVA) and ultraviolet B (UVB) therapy.

Therapy with PUVA is administered by the use of a photosensitiser prior to exposure to the phototherapy. The photosensitiser, psoralen, is administered either orally, or in bath water, or as a cream (or a gel) before exposure to long wavelength (320 to 400 nm) ultraviolet A (UVA) radiation. In consequence, PUVA is divided into oral PUVA, bath PUVA, and topical PUVA. With oral PUVA, different psoralens may be applied, such as 8-methoxypsoralen (8-MOP) and 5-methoxypsoralen (5-MOP). The psoralen 8-MOP is the only available orally prescribed psoralen in the United States; it takes about one to three hours to reach peak concentration in the skin, so is usually administered at least two hours before UV irradiation. The most common side-effect of PUVA is nausea that develops shortly after ingestion. Many people withdraw from PUVA therapy because of severe nausea. For those who cannot tolerate 8-MOP, 5-MOP is an alternative choice, which is more commonly used in Europe (Braun 2000; Jensen 2010; Menter 2010). Trimethylpsoralen, which is used for bath PUVA, is largely used in Scandinavia, whereas 8-MOP in a hydrophilic water or oil emulsion is used for topical PUVA (Jensen 2010; Menter 2010).

Therapy with PUVA has been proven to be effective for most forms of psoriasis and induces complete or partial remission in 79% to 90% of those with psoriasis (De Gruijl 1996; Lauharanta 1997; Morison 1998). Unfortunately, current evidence shows a clear correlation between cumulative PUVA exposure and an increased risk of skin cancer and premature ageing of the skin (Lauharanta 1997; Lowe 1997; Stern 1988). Therefore, the British Association of Dermatologists' guideline on biological interventions for psoriasis recommended that PUVA should be limited to 150 lifetime treatments, to decrease the risk of skin cancer (Smith 2009). However, a combined analysis of two cohort studies with 944 participants treated with bath PUVA "found no increase in the risk of squamous cell carcinoma after a mean follow-up of 14.7 years", suggesting that bath PUVA is possibly safer than oral PUVA (Naldi 2010).

UVB (spectrum light 280 to 320 nm) has been used to treat psoriasis for at least 90 years (Anderson 1984). There are several types of UVB radiation in clinical practice: 

  1. conventional broad-band UVB (BB-UVB) lamps, which deliver radiation in the range of 280 to 320 nm;
  2. selective BB-UVB, which has peaks at 305 to 325 nm; and
  3. narrow-band UVB (NB-UVB) lamps, which deliver almost exclusively 311 nm radiation (Braun 2000; Ibbotson 2004).

Conventional BB-UVB has been proven to cause the clearance of psoriasis within six weeks, but the use of it is limited by burning (Boer 1980). Selective BB-UVB was also effective in treating psoriasis (Parrish 1981). Phototherapy with NB-UVB was developed in the 1980s. It is emitted through Philips TL01 lamps and consists of a subset of the UVB spectrum between 311 and 313 nm. A study conducted by Parrish and Jaenicke demonstrated that the peak action spectrum for clinical antipsoriatic efficacy was between 308 and 312 nm (Fischer 1976; Parrish 1981). In this way, NB-UVB can theoretically achieve an optimal response while minimising the erythrogenic (redness of the skin) response to non-therapeutic wavelengths. In fact, several small-scale clinical studies (Coven 1997; Storbeck 1993; van Weelden 1988; Walters 1999) have shown an improved response of psoriasis to NB-UVB compared with conventional BB-UVB.

There is controversy regarding the risk of skin cancer with NB-UVB. Young 1995 summarised data from murine studies and reported NB-UVB might be two to three times more carcinogenic per minimal erythema dose (MED) than conventional BB-UVB. However, one systematic review (Pasker-de 1999) estimated that "the excess annual risk of non-melanoma skin cancer associated with UVB was likely to be less than 2%". Another systematic review found that UVB did not increase the risk of skin cancer during about 25 years' follow up (Lee 2005). Likewise, no increased risk of cancer was identified in 3867 people treated by NB-UVB in Scotland (Hearn 2008). Most recently, Archier 2012 found a lack of robust evidence of the carcinogenic risk of NB-UVB because of limited prospective studies.

Sometimes UVB or PUVA is combined with retinoids (e.g. etretinate and acitretin) to treat psoriasis. Retinoids have been established as an effective systemic therapy for psoriasis since the 1970s. They can be used as monotherapy or combined at low doses with UVB or PUVA for treating psoriasis. Etretinate was widely used initially; however, acitretin, the free acid of etretinate and its active metabolite, has replaced etretinate for treating psoriasis because of its more favourable pharmacokinetic profile (Saurat 1999). Generally, retinoids combined with NB-UVB or PUVA are abbreviated as re-NB-UVB or re-PUVA, respectively.

 

How the intervention might work

It has been found that UV exposure can affect cell signalling, favour development of T-helper 2 (Th2) immune responses, and reduce both the number and function of antigen-presenting Langerhans cells (Zanolli 2000).

Ultraviolet light in the UVA part of the spectrum is successfully used in the treatment of psoriasis, based on its ability to reduce mast cells and induce type I collagenase activity. Psoralen is used as a photosensitiser in PUVA therapy. Once psoralen is activated by UVA, "it crosslinks DNA strands, preventing replication of keratinocytes and inducing the death of activated T-cells in the skin" (Coven 1999). The significant effects of PUVA may be due to its immunosuppressive properties. The immunosuppressive mechanisms of PUVA mainly involve the following: decreasing the antigen-presenting capacity of epidermal Langerhans cells and the numbers and functional activity of T-helper cells and messenger RNA (mRNA) encoding for proinflammatory cytokines IL-6, IL-8, and TNF-α. They may also involve inhibition of cell proliferation, reduction of the percentage of CD3+ peripheral T lymphocytes producing IFN-gamma and IL-2, and induction of an anergy (failure of response) of type 1 activity in peripheral lymphocytes (Aubin 1998; Ashworth 1989; Borroni 1991; Kozenitzky 1992; Neuner 1994).

The exact mechanism of action of UVB is not fully understood. The proposed mechanism may cause apoptosis (cell death) of lymphocytes and epidermal cells, as well as immunosuppressive and anti-inflammatory effects (Aufiero 2006). It has been demonstrated that the peak action spectrum for clinical efficacy is between 308 and 312 nm, while the maximal erythrogenic response occurs around 297 nm (Fischer 1976; Parrish 1981). With NB-UVB, because the peak spectrum is at 311 nm, significant antipsoriatic efficacy can be achieved with a limited erythrogenic response.

The mechanism of the therapeutic effect of retinoids when combined with UVB or PUVA is also not yet fully understood. Pretreatment with retinoids can reduce "both desquamation and infiltration of psoriatic plaques", and in consequence might raise "the possibility of increased penetration of ultraviolet light" (Jensen 2010).

 

Why it is important to do this review

There have been many studies, of variable methodological quality, comparing the efficacy of different types of phototherapy. Some indicate that PUVA is more effective than BB-UVB radiation (Brenner 1983; Boer 1984; Honigsmann 1977; Morison 1995); others demonstrate that NB-UVB provides faster clearing of psoriasis, less burning reactions, and longer periods of remission than BB-UVB phototherapy (Coven 1997; Green 1988; Storbeck 1993). NB-UVB is also more convenient because no exogenous photosensitiser is needed before phototherapy. Recently, while some authors have claimed that NB-UVB therapy has similar efficacy to PUVA (Markham 2003), other authors (Dawe 2003; Gordon 1999; Tahir 2004) have found different results.

No systematic review has been conducted to summarise the evidence of the effects of NB-UVB phototherapy compared with BB-UVB or PUVA photochemotherapy for psoriasis. Therefore, we aimed to summarise results from randomised controlled trials (RCTs) to provide reliable evidence for clinicians and for those with psoriasis.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

To assess the effects of narrow-band ultraviolet B phototherapy versus broad-band ultraviolet B or psoralen ultraviolet A photochemotherapy for psoriasis.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included any RCT involving NB-UVB phototherapy versus BB-UVB or PUVA photochemotherapy for psoriasis. We excluded quasi-randomised trials.

 

Types of participants

We included any individual with a diagnosis of any type of psoriasis, regardless of age, race, gender, or the severity of their lesions.

 

Types of interventions

Any NB-UVB phototherapy compared with BB-UVB or PUVA photochemotherapy, either as a single or combination therapy. The following comparisons were performed:

  • NB-UVB versus oral PUVA;
  • NB-UVB versus bath PUVA;
  • NB-UVB versus topical PUVA;
  • NB-UVB combined with retinoids (re-NB-UVB) versus PUVA combined with retinoids (re-PUVA);
  • NB-UVB versus selective BB-UVB;
  • NB-UVB versus conventional BB-UVB; and
  • NB-UVB combined with dithranol versus BB-UVB combined with dithranol.

 

Types of outcome measures

 

Primary outcomes

  1. Participant-rated global improvement.
  2. Percentage of participants reaching Psoriasis Area and Severity Index (PASI) 75 (which meant equal to or more than 75% reduction in PASI score).
  3. Withdrawal due to side-effects.
  4. Clearance rate. (Clearance was defined as no lesions of psoriasis or minimal residual activity (MRA)).

 

Secondary outcomes

  1. The Physician's Global Evaluation score.
  2. Dermatology Life Quality Index (DLQI).
  3. Number of treatments to clearance.
  4. Cumulative UV dose to clearance.
  5. Time to clearance.
  6. Clearance lasting six months.
  7. PASI score reduction (before and after treatment).
  8. Time to PASI 75.
  9. Relapse rate.
  10. Duration of remission.
  11. Withdrawal due to poor response.
  12. Clinical improvement.
  13. Reduction of peripheral T cells.
  14. Tolerability.
  15. Adverse events.

 

Search methods for identification of studies

We aimed to identify all relevant randomised controlled trials (RCTs) regardless of language or publication status (published, unpublished, in press, or in progress).

 

Electronic searches

We searched the following databases up to 8 August 2013:

  • the Cochrane Skin Group Specialised Register using the search strategy in Appendix 1;
  • the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 7, 2013, in The Cochrane Library using the search strategy in Appendix 2;
  • MEDLINE via OVID (from 1946) using the strategy in Appendix 3; and
  • EMBASE via OVID (from 1974) using the strategy in Appendix 4.

We searched the following databases up to 27 November 2012:

  • CNKI (China National Knowledge Infrastructure, from 1974) using the strategy in Appendix 5; and
  • CBM (Chinese Biomedical Database, from 1978) using the strategy in Appendix 6.

 

Searching other resources

 

Trials registers

We searched the following trials registers using the strategy in Appendix 7 on 27 November 2012:

 

Reference lists

We scanned the references of all included trials and relevant systematic reviews or meta-analyses to identify further relevant trials.

 

Conference proceedings

We handsearched abstracts from the following dermatological conference proceedings for further RCTs up to November 2012:

  • World Congress of Dermatology (from 1980);
  • International Congress of Dermatology (from 1980); and
  • European Academy of Dermatology and Venereology (from 1980).

 

Unpublished literature

We searched the OpenGrey database (www.opengrey.eu) for grey literature using the search strategy in Appendix 7.

We were not able to contact authors to obtain unpublished trials, as we had planned, because of time and resource constraints.

 

Adverse effects

We did not perform a separate search for adverse effects of the target interventions. We considered data on adverse effects from the included studies we identified.

 

Data collection and analysis

 

Selection of studies

Two review authors (XMC and YC) independently scanned the titles and abstracts of all articles identified from the searches according to our inclusion and exclusion criteria. For all initially selected articles, we obtained the full text; thereafter, two review authors (XMC and MY) independently assessed them to see whether they were eligible for inclusion.

We listed the studies that were excluded and the reasons for their exclusion in the review. During this process, we resolved discrepancies by discussion with MZ, who acted as an arbitrator.

 

Data extraction and management

Two review authors (XMC and MY) extracted the data from the included studies separately. We documented the process of resolving discrepancies in this review. We used the standard data extraction form recommended by the Cochrane Skin Group and recorded information about the following areas:

  • general information (authors, title, source, year of publication, language of publication, trial numbers);
  • trial characteristics (design; manner of recruitment; inclusion and exclusion criteria; duration of intervention period; reason for, and number of, dropouts and withdrawals);
  • participants (baseline characteristics of participants in all groups, such as gender, age, psoriasis severity, and baseline health-related quality of life (HRQoL) scores);
  • interventions (any intervention in both study and control groups); and
  • outcomes (specific outcomes reported, assessment instrument used, adverse events).

We tried to contact trial authors for more information where necessary. One of us (MY) checked and entered the data into Review Manager (RevMan). Another author (XMC) double-checked the data. We resolved disagreements by discussion within the review team.

 

Assessment of risk of bias in included studies

Two authors (XMC and MY) independently assessed the methodological quality of the included studies. We settled discrepancies by discussion within the review team. We used The Cochrane Collaboration's tool for assessing risk of bias, which forms part of the 'Characteristics of included studies' tables (Higgins 2011), and we addressed the following issues:

(a) was there adequate sequence generation?;
(b) was allocation adequately concealed?;
(c) was knowledge of the allocated interventions adequately prevented during the study?;
(d) were incomplete outcome data adequately addressed?;
(e) were reports of the study free of suggestion of selective outcome reporting?; and
(f) was the study apparently free of other problems that could put it at a risk of bias?

We documented our judgements for each item and the reasons for our judgements in the 'Risk of bias' table for each included study within the review.

Where necessary, we attempted to contact trial authors for more information.

 

Measures of treatment effect

According to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), we defined measures of treatment effects as follows.

 

Dichotomous data

We presented dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CIs) for individual trials. We discussed the main outcomes of each study and, if possible, pooled feasible data.

 

Continuous data

For continuous variables, such as the score of life quality index, we used the mean difference and 95% CI, unless different scales were used in the trials, in which case we used a standardised mean difference (SMD) and 95% CI to summarise the data.

 

Unit of analysis issues

 

Simple parallel RCTs

The unit of analysis was individual participants.

 

Cluster RCTs

In the protocol, we stated that if we identified cluster RCTs, we would try to re-analyse these trials by calculating the effective sample sizes according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), and if possible, we would calculate an estimate of the intracluster coefficient (ICC), using external estimates obtained from similar trials. We would not pool data from cluster RCTs with those from parallel RCTs. However, we found no eligible cluster trials.

 

Cross-over RCTs

In the protocol, we stated that if we identified cross-over RCTs, we would only extract and analyse data from the first period (Higgins 2011). We would not pool data from cross-over RCTs with those from parallel RCTs. However, we found no eligible cross-over RCTs.

 

Multiple intervention groups within a trial

No relevant trial was included in this review. If we identify relevant trials for future updates of this review, we will deal with them as we planned in the published protocol.

 

Multiple body parts receiving the same intervention

No relevant trial was included in this review. If we identify relevant trials for future updates of this review, we will deal with them as we planned in the published protocol.

 

Multiple body parts receiving different interventions

In some included trials, the left and right sides of the body were randomly allocated into different groups and to receive different interventions. In this regard, the unit of analysis was half-body.

 

Dealing with missing data

First, we attempted to contact the trial authors to get more information where necessary. If this did not succeed, we considered participants with missing outcomes as treatment failures for dichotomous outcomes. In the case of participant dropout, we conducted intention-to-treat (ITT) analyses for primary outcomes.

For continuous outcomes, we only extracted and analysed the available data. In addition, we explored the impact of missing data on the treatment effect by using sensitivity analyses, where possible. In future updates, if there were missing continuous data, we would state the whole process of dealing with the missing data and its potential impact on the results of the review in the Discussion section of our review.

 

Assessment of heterogeneity

We evaluated the level of clinical heterogeneity by comparing the differences between the trials in the administration of therapy, the type of comparators used, and the characteristics of the study population. If an appropriate level of clinical homogeneity existed, we analysed the level of statistical heterogeneity using the Chi² test on N-1 degrees of freedom, with an alpha of 0.1 used for statistical significance and the I² statistic. I² statistic values of 25%, 50%, and 75% correspond to low, medium, and high levels of heterogeneity (Higgins 2011). If heterogeneity existed, we attempted to probe the reasons for it and advised caution in the interpretation of our results.

 

Assessment of reporting biases

If we had identified sufficient RCTs, we would have used funnel plots to test for publication bias. However, we could not use funnel plots to test for publication bias, because for each outcome, there were insufficient studies to perform it (Higgins 2011).

 

Data synthesis

We pooled data using the random-effects model, unless there were less than three trials without clinical heterogeneity - in which case, we used the fixed-effect model. If we identified substantial heterogeneity, we reported the results qualitatively.

 

Subgroup analysis and investigation of heterogeneity

Because of insufficient information, we could only perform subgroup analysis to detect the potential heterogeneity induced by study design (e.g. some studies performed left-right body comparisons, while others performed comparisons between participants) in some outcomes.

 

Sensitivity analysis

In the protocol, we stated that we would perform sensitivity analyses, where possible, but we were unable to carry this out because of insufficient data.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Description of studies

See the 'Characteristics of included studies', 'Characteristics of excluded studies', and 'Studies awaiting classification' tables.

 

Results of the search

Our electronic search retrieved 1798 references excluding duplicates. After scanning the titles and abstracts, we identified 25 references as potentially relevant, which we retrieved in full text. Among these, 17 references referring to 13 RCTs met the inclusion criteria. One reference (Nazari 2005) was published in Turkish, and we are waiting for a translation. It is listed in Characteristics of studies awaiting classification. We excluded the remaining seven references. We identified no further reports by screening the reference lists of all included RCTs, relevant systematic reviews or meta-analyses, and dermatological conference proceedings. We present the screening process in Figure 1.

 FigureFigure 1. Study flow diagram

 

Included studies

In this review, we included 13 RCTs, with a total of 662 participants. More information about these 13 studies (Chauhan 2011; Dawe 2003; Gordon 1999; Green 1992; Kirke 2007; Larko 1989; Markham 2003; Özdemir 2008; Salem 2010; Sezer 2007; Snellman 2004; Storbeck 1993; Yones 2006) is available in the 'Characteristics of included studies' tables.

 

Design

Some of the included RCTs (Chauhan 2011; Green 1992; Gordon 1999; Kirke 2007; Markham 2003; Özdemir 2008; Salem 2010; Yones 2006) performed comparisons between participants, whereas others (Dawe 2003; Larko 1989; Sezer 2007; Snellman 2004; Storbeck 1993) performed within-patient comparisons (left-right body comparison).

 

Sample sizes

With regard to the size of the individual trials, participant numbers ranged from 18 to 100.

 

Setting

The included RCTs were published from 1989 to 2011. Five of them were conducted in the UK (Dawe 2003; Gordon 1999; Green 1992; Kirke 2007; Yones 2006); two, in Turkey (Özdemir 2008; Sezer 2007); the remaining RCTs were conducted in India (Chauhan 2011), Ireland (Markham 2003), Sweden (Larko 1989), Egypt (Salem 2010), Finland (Snellman 2004), and Germany (Storbeck 1993), respectively.

 

Participants

Most of the included studies recruited adults (≥18 years of age) except for two RCTs (Salem 2010; Storbeck 1993), which recruited participants aged from 13 to 63 years and 17 to 66 years, respectively. In addition, another RCT (Green 1992) did not report the age of the participants.

Most of the included RCTs (Chauhan 2011; Dawe 2003; Gordon 1999; Kirke 2007; Markham 2003; Özdemir 2008; Snellman 2004; Yones 2006) focused on chronic plaque psoriasis (CPP), and one RCT (Sezer 2007) paid attention to palmoplantar psoriasis (PPP), while the remaining RCTs (Green 1992; Larko 1989; Salem 2010; Storbeck 1993) included people with different kinds of psoriasis.

 

Interventions

The following comparisons were identified:

In most included trials, NB-UVB was performed three times weekly, except in two trials (Gordon 1999; Yones 2006), which carried out NB-UVB twice a week. In addition, BB-UVB was conducted three to five times weekly (Kirke 2007; Larko 1989; Storbeck 1993); bath PUVA, two (Dawe 2003) or three (Salem 2010; Snellman 2004) times weekly; oral PUVA was performed two (Gordon 1999; Green 1992; Markham 2003; Yones 2006) or three (Chauhan 2011; Özdemir 2008) times weekly; and topical PUVA was conducted three times weekly (Sezer 2007).

 

Outcomes

Outcome measurements were very variable. For example, some included RCTs reported "complete clearance" as their primary outcome, whereas others applied "minimal residual activity (MRA)" or clearance; some applied Psoriasis Area and Severity Index (PASI) score reduction to assess the improvement of psoriasis, whereas others presented the percentage of participants who achieved PASI 75 (which meant equal to or more than 75% reduction in PASI score). It was noteworthy that most of these outcomes were on the basis of judgement from clinicians and were subjective and relatively imprecise. Only one trial (Özdemir 2008) reported the tolerability of the treatment assessed by the participants themselves. Another trial (Yones 2006) assessed the participants' QOL, which is often omitted in clinical practice.

 

Excluded studies

We excluded seven studies. Our reasons for exclusion are shown in the 'Characteristics of excluded studies' tables.

 

Risk of bias in included studies

We applied The Cochrane Collaboration's tool for assessing risk of bias. Figure 2 and Figure 3 illustrate the overall risk of bias.

 FigureFigure 2. 'Risk of bias' summary: Review authors' judgements about each 'Risk of bias' item for each included study
 FigureFigure 3. 'Risk of bias' graph: Review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies

 

Allocation

Randomisation and concealment of allocation are thought to be essential components of a RCT to minimise bias. All included trials were reported as "randomised"; however, in five of them (Green 1992; Larko 1989; Markham 2003; Salem 2010; Storbeck 1993), no further methodological details were given, so we assessed these as having an 'unclear' risk of bias for this domain. In four of the included RCTs (Dawe 2003; Sezer 2007; Snellman 2004; Storbeck 1993), randomisation was conducted within participants; in other words, the left and right side of the participant's body were randomly allocated into different groups.

Seven included RCTs (Larko 1989; Markham 2003; Özdemir 2008; Salem 2010; Sezer 2007; Storbeck 1993; Yones 2006) did not explicitly report whether allocation concealment was performed or not, so we assessed these as having an unclear risk of bias for this domain. Another RCT (Chauhan 2011) clearly stated that "the random allocation list was not concealed," so we assessed this as at a high risk of bias for this domain.

 

Blinding

We evaluated blinding of participants and personnel and blinding of outcome assessment separately. We applied the former to check performance bias, whereas the latter was to check detection bias. Only one RCT (Yones 2006) performed blinding of participants and personnel. The reason may be that different devices and therapy schemes are needed to perform different types of UV irradiation, and consequently, it is hard to mask phototherapists and participants. In addition, eight RCTs (Dawe 2003; Gordon 1999; Kirke 2007; Özdemir 2008; Salem 2010; Sezer 2007; Snellman 2004; Yones 2006) performed blinding of the outcome assessment.

 

Incomplete outcome data

We labelled 10 of the 13 included studies as 'low risk of bias' in this regard. In most of the included trials, the rate of dropouts was lower than 20%, and the reasons were clearly reported and the withdrawals distributed equally between the groups. To be more specific, the rate of discontinuation in the included studies ranged from 0% (Green 1992; Storbeck 1993) to 36% (Dawe 2003). It was less than 10% in five RCTs (Gordon 1999; Green 1992; Salem 2010; Storbeck 1993; Yones 2006), 10% to 20% in six RCTs (Chauhan 2011; Kirke 2007; Markham 2003; Özdemir 2008; Sezer 2007; Snellman 2004), and more than 20% in one RCT (Dawe 2003). In Chauhan 2011, 16% of the participants discontinued the trial, and when assessing "time to relapse", only 57% of the participants were available for analysis. We assessed this study at 'high risk of bias'. One RCT (Larko 1989) did not report the rate of discontinuation, so we assessed this as unclear.

An intention-to-treat (ITT) analysis is often recommended as the least biased way to estimate intervention effects in RCTs (Higgins 2011). Three included RCTs (Dawe 2003; Kirke 2007; Snellman 2004) applied ITT analyses. In Dawe 2003, 10 (36%) participants discontinued the study, which might have induced significant attrition bias. As a result, we labelled this trial as 'high risk of bias', although ITT analyses were applied.

 

Selective reporting

Almost all included trials had no preliminarily published protocol or were not registered in any clinical trial database, except for one (Kirke 2007). In five trials (Dawe 2003; Kirke 2007; Salem 2010; Snellman 2004; Yones 2006), all outcomes described in their methods section were reported appropriately with statistical data in the results section, and in consequence, we labelled them as 'low risk of bias'. In two trials (Gordon 1999; Özdemir 2008), there was insufficient information to make a judgement. We labelled four RCTs (Larko 1989; Markham 2003; Sezer 2007; Storbeck 1993) at 'high risk of bias' where some outcomes were not supported by statistical data. Chauhan 2011 did not report in their results section some outcomes described in their methods section, and in Green 1992, the authors reported mean and range in the main outcomes, but not P values or 95% CIs, so we labelled these two studies as at 'high risk of bias' for this domain.

 

Other potential sources of bias

Five trials (Dawe 2003; Larko 1989; Sezer 2007; Snellman 2004; Storbeck 1993) conducted randomisation within participants, and as a result, withdrawal of one half-body for any reason inevitably caused withdrawal of the other half. In addition, because each participant received both treatment regimens, the treatment to one side might have affected the other. These effects might have induced other potential biases. In the other eight trials, there was insufficient information to make a judgement.

 

Effects of interventions

See:  Summary of findings for the main comparison NB-UVB compared with oral PUVA for chronic plaque psoriasis;  Summary of findings 2 NB-UVB compared with bath PUVA for chronic plaque psoriasis;  Summary of findings 3 NB-UVB compared with topical PUVA for palmoplantar psoriasis;  Summary of findings 4 NB-UVB plus retinoid compared with PUVA plus retinoid for chronic plaque or guttate psoriasis;  Summary of findings 5 NB-UVB compared with selective BB-UVB for chronic plaque psoriasis

We made the decision to move one of our prespecified secondary outcomes to primary outcome 4 and rename it 'clearance rate'. We also added further outcomes to our secondary outcomes. We have explained our reasoning for making this change to our published protocol in the Differences between protocol and review section.

Please read this section with the following summaries:

 

1. NB-UVB compared with oral PUVA for chronic plaque psoriasis

 

Primary outcomes

 
1) Participant-rated global improvement

No included RCTs addressed this outcome for this comparison.

 
2) Percentage of participants reaching PASI 75

Only one trial (Chauhan 2011) reported the percentage of participants with chronic plaque psoriasis (CPP) who reached PASI 75. Seventeen of 21 (80.9%) participants in the NB-UVB group compared with 18 of 22 (81.8%) participants in the oral PUVA group reached PASI 75; the difference was not statistically significant (RR 0.99, 95% CI 0.74 to 1.32; N = 43;  Analysis 1.1). Chauhan 2011 did not perform ITT analysis. As mentioned in the Methods section, we considered participants with missing outcomes as treatment failures for dichotomous outcomes and conducted ITT analysis. The result indicated that no significant difference was identified between NB-UVB and oral PUVA groups (RR 0.91, 95% CI 0.63 to 1.32; N = 51;  Analysis 1.2).

 
3) Withdrawal due to side-effects

Pooled data from three trials (Gordon 1999; Markham 2003; Yones 2006) indicated that withdrawals due to adverse events were not significantly different between the NB-UVB group and the oral PUVA group in participants with CPP (RR 0.69, 95% CI 0.19 to 2.43; N = 231;  Analysis 1.3). The ITT analysis revealed a similar result (RR 0.71, 95% CI 0.20 to 2.54; N = 247;  Analysis 1.4).

 
4) Clearance rate

Three trials (Gordon 1999; Markham 2003; Yones 2006) compared NB-UVB to oral PUVA with respect to clearance rate in participants with CPP. Because we identified statistically significant heterogeneity between the three studies (I² statistic = 91%), we did not pool the data. Among them, Yones 2006 did not perform ITT analysis, and the result showed that the clearance rate was 51.1% in the NB-UVB group and 79.1% in the oral PUVA group (RR 0.65, 95% CI 0.47 to 0.89; N = 88;  Analysis 1.5). We conducted ITT analysis using the data of Yones 2006 and found a very similar result: The clearance rate was 48.9% in the NB-UVB group and 73.9% in the oral PUVA group (RR 0.66, 95% CI 0.47 to 0.93; N = 93;  Analysis 1.6). Gordon 1999 performed ITT analysis and found that the clearance rate was 62.7% in the NB-UVB group and 83.7% in the oral PUVA group (RR 0.75, 95% CI 0.59 to 0.96; N = 100;  Analysis 1.6). Markham 2003 also performed ITT analysis; however, there was no significant difference between the NB-UVB and the oral PUVA groups with respect to clearance rate (96.6% versus 96%; RR 1.01, 95% CI 0.91 to 1.12; N = 54;  Analysis 1.6).

 

Secondary outcomes

 
1) The Physician's Global Evaluation score

No included RCTs addressed this outcome for this comparison.

 
2) Dermatology Life Quality Index (DLQI)

Yones 2006 reported DLQI as an outcome in participants with CPP, which is a simple practical tool for assessing the QOL of people with skin diseases (Finlay 1994). The reduction of DLQI scores was statistically significantly greater in the oral PUVA group than in the NB-UVB group (the Mann-Whitney test, Z = -2.4, P = 0.02). In other words, the participants' QOL in the oral PUVA group was improved more than in the NB-UVB group.

 
3) Number of treatments to clearance

Three included trials (Gordon 1999; Markham 2003; Yones 2006) reported this outcome in participants with CPP. We could not perform meta-analysis because of insufficient data. Gordon 1999 showed the median number of treatments to clearance was 25.3 for NB-UVB and 16.7 for oral PUVA (P < 0.001). Markham 2003 reported the median number of treatments to clearance was 25.5 for NB-UVB and 19 for oral PUVA (the Mann-Whitney test, P = 0.03). Yones 2006 found the median number of treatments to clearance was 28.5 for NB-UVB and 17 for oral PUVA, and the difference was statistically significant (the Mann-Whitney test, Z = -3.7, P < 0.01).

 
4) Cumulative UV dose to clearance

There is evidence that lower cumulative UV dose is relevant to lower risk of skin cancer (Godar 2003). In the study by Gordon 1999, in participants with CPP, the median cumulative UV dose to clearance was 35 J/cm² for NB-UVB and 75.1 J/cm² for oral PUVA. However, the study authors did not clearly describe whether the difference between the two groups was statistically significant.

 
5) Time to clearance

In the study by Markham 2003, in people with CPP, the median time to clearance in the NB-UVB group was 66 days, whereas it was 67 days in the oral PUVA group. The difference between the two groups did not reach statistical significance (P = 0.46).

 
6) Clearance lasting six months

In the study by Yones 2006 in people with CPP, more skin lesions in the oral PUVA group achieved clearance lasting six months, which was statistically significant compared with those in the NB-UVB group (RR 0.51, 95% CI 0.28 to 0.94; N = 47;  Analysis 1.7).

 
7) PASI score reduction (before and after treatment)

No included RCTs addressed this outcome for this comparison.

 
8) Time to PASI 75

In the study by Chauhan 2011, in participants with CPP, the mean time to PASI 75 was 9.9 weeks in both NB-UVB and oral PUVA groups (mean difference (MD) 0.00, 95% CI -2.03 to 2.03; N = 43;  Analysis 1.8).

 
9) Relapse rate

Three included trials, which were conducted in participants with CPP, reported this outcome (Chauhan 2011; Gordon 1999; Markham 2003). Pooled data showed that the lesions in 36 of 90 (40%) participants who received NB-UVB compared with 31 of 82 (37.8%) participants who received oral PUVA group relapsed at six months after treatment completion, but the difference between groups did not reach statistical significance (RR 1.08, 95% CI 0.74 to 1.58; N = 162;  Analysis 1.9). These studies defined relapse as 50% of the original extent of the lesions.

 
10) Duration of remission

In the study by Markham 2003, the median duration of remission for participants with CPP was 288.5 days in the NB-UVB group and 231 days in the oral PUVA group; however, the difference between groups was not statistically significant (P = 0.40). The study did not explicitly define remission.

 
11) Withdrawal due to poor response

In the study by Gordon 1999, in participants with CPP, withdrawals due to poor response were significantly more in the NB-UVB group than in the oral PUVA group (29.4% versus 6%; RR 4.80, 95% CI 1.48 to 15.57; N = 100;  Analysis 1.10).

 
12) Clinical improvement

No included RCTs addressed this secondary outcome for this comparison.

 
13) Reduction of peripheral T cells

No included RCTs addressed this secondary outcome for this comparison.

 
14) Tolerability

No included RCTs addressed this secondary outcome for this comparison.

 
15) Adverse events

Four RCTs (Chauhan 2011; Gordon 1999; Markham 2003; Yones 2006) addressed the following adverse events conducted in participants with CPP: erythema (in different degrees), pruritus, polymorphic light eruption (PMLE), nausea, and folliculitis ( Analysis 1.11). They were generally slight and reversible. Chauhan 2011 indicated that the incidence of any adverse events was not significantly different between NB-UVB and PUVA groups (RR 0.92, 95% CI 0.40 to 2.08; N = 43;  Analysis 1.11, see Analysis 1.11.7).

Pooled data from three trials (Gordon 1999; Markham 2003; Yones 2006) indicated that the incidence of erythema was comparable between NB-UVB and oral PUVA groups (RR 0.99, 95% CI 0.47 to 2.09; N = 233;  Analysis 1.11, see Analysis 1.11.1). Similarly, no significant difference was identified between NB-UVB and oral PUVA groups with respect to grade one erythema (Markham 2003; RR 0.93, 95% CI 0.68 to 1.26; N = 45;  Analysis 1.11, see Analysis 1.11.5) and grade two erythema (Yones 2006; RR 0.48, 95% CI 0.13 to 1.79; N = 88;  Analysis 1.11, see Analysis 1.11.6).

Pooled data from two trials (Chauhan 2011; Yones 2006) showed the incidence of nausea was significantly lower in the NB-UVB group than in the oral PUVA group (0% versus 12.3%; RR 0.12, 95% CI 0.02 to 0.94; N = 131;  Analysis 1.11, see Analysis 1.11.2).

Furthermore, Chauhan 2011 found that the incidence of pruritus was not significantly different between NB-UVB and PUVA groups (23.8% versus 27.3%; RR 0.87, 95% CI 0.31 to 2.43; N = 43;  Analysis 1.11, see Analysis 1.11.3), or between the NB-UVB and PUVA groups with respect to PMLE (9% versus 9.5%; RR 1.05, 95% CI 0.16 to 6.77; N = 43;  Analysis 1.11, see Analysis 1.11.4).

 

2. NB-UVB compared with bath PUVA for chronic plaque psoriasis

 

Primary outcomes

Only one primary outcome was addressed for this comparison.

 
4) Clearance rate

Three trials (Dawe 2003; Salem 2010; Snellman 2004) compared NB-UVB to bath PUVA in participants with CPP. Among them, Dawe 2003 and Snellman 2004 conducted left-right body comparisons while Salem 2010 conducted comparisons between participants. Pooled data from Dawe 2003 and Snellman 2004 indicated that no significant difference between the two groups were identified (RR 2.03, 95% CI 0.29 to 14.06; N = 35;  Analysis 2.1). However, Salem 2010 found that two of 16 participants (12.5%) in the NB-UVB group compared with 11 of 18 participants (61.1%) in the bath PUVA groups achieved statistically significant clearance (RR 0.20, 95% CI 0.05 to 0.79; N = 34;  Analysis 2.1). Because we identified moderate statistical heterogeneity between Dawe 2003 and Snellman 2004 (I² statistic = 74%), the pooled data should be interpreted with caution.

Additionally, we conducted ITT analyses. The pooled data from Dawe 2003 and Snellman 2004 indicated that no significant difference between the two groups was identified (RR 1.79, 95% CI 0.46 to 6.91; N = 46;  Analysis 2.2). Again, because of the moderate statistical heterogeneity between Dawe 2003 and Snellman 2004 (I² statistic = 52%), the pooled data should be interpreted with caution. However, the ITT analysis of Salem 2010 found that more participants in the bath PUVA group achieved clearance than those in the NB-UVB group (RR 0.18, 95% CI 0.18 to 0.71; N = 36;  Analysis 2.2).

 

Secondary outcomes

The following four of our secondary outcomes were addressed for this comparison.

 
3) Number of treatments to clearance

Dawe 2003 showed that the median number of treatments to clearance for participants with CPP was 24.5 for NB-UVB and 19 for bath PUVA, and the difference was statistically significant (P = 0.001).

 
7) PASI score reduction (before and after treatment)

Salem 2010 compared the PASI score reduction before and after therapy between groups in participants with CPP. The greater the reduction in score, the better the improvement in the lesions. The mean PASI score reduction was 11.71 in the NB-UVB group and 22.51 in the bath PUVA group (MD -10.80, 95% CI -16.23 to -5.37; N = 34;  Analysis 2.3), which was statistically in favour of bath PUVA. In the study by Dawe 2003, the median PASI score reduction was 20 in the NB-UVB group and 17.5 in the bath PUVA group (P = 0.04).

 
13) Reduction of peripheral T cells

In the study by Salem 2010, in participants with CPP, the mean reduction (before-after treatment values) of percentage of CD4+ T cells was significantly lower in NB-UVB group than in the bath PUVA group (P = 0.03), but there was no significant difference between groups with respect to the mean change of CD8+ T cells (P = 0.27).

 
15) Adverse events

The following adverse events were addressed in three RCTs (Dawe 2003; Salem 2010; Snellman 2004) conducted in participants with CPP: erythema (in different degrees), pruritus, and folliculitis ( Analysis 2.4).

Salem 2010 (N = 34) found no significant difference between groups with respect to the incidence of erythema (RR 1.13, 95% CI 0.18 to 7.09; N = 34; see Analysis 2.4.1), pruritus (RR 0.84, 95% CI 0.22 to 3.21; N = 34; see Analysis 2.4.2), and folliculitis (RR 0.37, 95% CI 0.02 to 8.55; N = 34; see Analysis 2.4.6).

The study by Dawe 2003 (N = 28) found no significant difference between groups in terms of grade one erythema (RR 1.31, 95% CI 0.89 to 1.93; see Analysis 2.4.3), grade two erythema (RR 1.25, 95% CI 0.58 to 2.69; see Analysis 2.4.4), and grade three erythema (RR 1.00, 95% CI 0.28 to 3.61; see Analysis 2.4.5).

However, Snellman 2004 (N = 17) found that erythema was more frequent in the NB-UVB group than in the PUVA group (RR 1.52, 95% CI 1.07 to 2.17; see Analysis 2.4.1), which was statistically significant.

 

3. NB-UVB compared with topical PUVA for palmoplantar psoriasis

 

Primary outcomes

Only one primary outcome was addressed for this comparison.

 
4) Clearance rate

Sezer 2007 conducted this within-patient study on people with PPP. Compared with the topical PUVA treated sides, the NB-UVB treated sides appeared harder to achieve clearance (0% versus 23.8%). However, the difference did not reach statistical significance (RR 0.09, 95% CI 0.01 to 1.55; N = 21;  Analysis 3.1). Sezer 2007 did not perform ITT analysis. However, we carried out ITT analysis. The ITT analysis gave a very similar result (RR 0.09, 95% CI 0.01 to 1.56; N = 25;  Analysis 3.2).

 

Secondary outcomes

The following three of our secondary outcomes were addressed for this comparison.

 
9) Relapse rate

In the study by Sezer 2007, the skin lesions in 12 of 21 (57.1%) NB-UVB treated sides compared with seven of 21 (33.3%) topical PUVA treated sides relapsed at nine weeks after treatment completion, but the difference was not statistically significant (RR 1.71, 95% CI 0.84 to 3.48; N = 21;  Analysis 3.3). Relapse was defined as an increase in post-treatment Severity Index scores of PPP (see  Table 1).

 
12) Clinical improvement

Sezer 2007 compared the effect of NB-UVB to topical PUVA in participants with PPP. The trial found that 42.9% of the sides treated with NB-UVB achieved marked clinical improvement, while 71.4% of those sides treated with topical PUVA achieved marked clinical improvement, but the difference was not statistically significant (RR 0.60, 95% CI 0.34 to 1.05; N = 21;  Analysis 3.4). In this study, marked clinical improvement was defined as those who had a reduction of 70% or more with respect to the baseline Severity Index scores at nine weeks.

 
15) Adverse events

Sezer 2007 reported the following adverse events: phototoxicity, palmar hyperpigmentation, and mild xerosis. In this study, one participant dropped out because of a phototoxic reaction in the PUVA treated side. The incidence of palmar hyperpigmentation was significantly lower in the NB-UVB treated side than in the PUVA treated side (0% versus 52.4%; RR 0.04, 95% CI 0.00 to 0.69; N = 21;  Analysis 3.5). Mild xerosis was observed on both sides of the body and responded to emollients.

 

4. NB-UVB plus retinoid (re-NB-UVB) compared with PUVA plus retinoid (re-PUVA) for chronic plaque or guttate psoriasis

 

Primary outcomes

Two of our primary outcomes were addressed for this comparison.

 
2) Percentage of participants reaching PASI 75

Only one trial (Özdemir 2008) addressed this comparison in participants with chronic plaque and guttate psoriasis. Özdemir 2008 found no significant difference between the two groups with respect to PASI 75 (RR 0.83, 95% CI 0.58 to 1.19; N = 52;  Analysis 4.1). Özdemir 2008 also reported the result of ITT analysis: 17 of 30 (56.7%) participants in the retinoid NB-UVB group compared with 19 of 30 (63.3%) in the retinoid PUVA group reached PASI 75, but the difference between groups was not statistically significant (RR 0.89, 95% CI 0.59 to 1.35; N = 60;  Analysis 4.2).

 
4) Clearance rate

Özdemir 2008 and Green 1992 addressed this comparison in people with chronic plaque and guttate psoriasis; pooled data found no significant difference between those who were treated with re-NB-UVB and those who treated re-PUVA in terms of clearance rate (RR 0.91, 95% CI 0.78 to 1.07; N = 82;  Analysis 4.3). ITT analysis of the pooled data gave a very similar result (RR 0.93, 95% CI 0.79 to 1.10; N = 90;  Analysis 4.4).

 

Secondary outcomes

The following five of our secondary outcomes were addressed for this comparison.

 
7) PASI score reduction (before and after treatment)

In the study by Özdemir 2008, in participants with chronic plaque and guttate psoriasis, the mean PASI score reduction was not significantly different between the re-NB-UVB group and the re-PUVA group (11.4 versus 12.6, P = 0.83).

 
9) Relapse rate

Green 1992 found no significant difference between re-NB-UVB and re-PUVA with respect to relapse at six months after treatment completion (60% versus 46.7%; RR 1.29, 95% CI 0.65 to 2.54; N = 30;  Analysis 4.5). Relapse was defined as a return of psoriasis to 50% or more of that at baseline.

 
12) Clinical improvement

Özdemir 2008 (N = 60) reported the percentage of participants who achieved a marked improvement (which was defined as 50% to 75% improvement in PASI score), moderate improvement (which referred to 25% to 50% improvement in PASI score), slight improvement (which referred to 5% to 25% improvement in PASI score), or no improvement (which was defined as less than 5% improvement in PASI score). Using ITT analyses, no significant differences were found between the re-NB-UVB group and the re-PUVA group with respect to marked improvement (RR 1.00, 95% CI 0.28 to 3.63;  Analysis 4.6, see Analysis 4.6.1), moderate improvement (RR 4.00, 95% CI 0.47 to 33.73;  Analysis 4.6, see Analysis 4.6.2), slight improvement (RR 2.00, 95% CI 0.19 to 20.90;  Analysis 4.6, see Analysis 4.6.3), or no improvement (RR 0.60, 95% CI 0.16 to 2.29;  Analysis 4.6, see Analysis 4.6.4).

 
14) Tolerability

Özdemir 2008 (N = 60) showed there was no significant difference in the tolerability of re-NB-UVB or re-PUVA when assessed by the clinicians (RR 1.05, 95% CI 0.76 to 1.44;  Analysis 4.7) or by the participants themselves (RR 1.05, 95% CI 0.73 to 1.53;  Analysis 4.8).

 
15) Adverse events

Two RCTs (Green 1992; Özdemir 2008) addressed the following adverse events: erythema; pruritus; burning; diffuse hair loss; nausea; reversible hypertriglyceridaemia; dry lips, mouth, skin, and nose; joint pain; nose bleeding; taste loss; muscle pain; paronychia; xerophthalmia; nail fragility; headache; and gastrointestinal events.

In  Analysis 4.9, no significant differences were identified between re-NB-UVB and re-PUVA with respect to the incidence of erythema (RR 1.32, 95% CI 0.60 to 2.94; N = 52; see Analysis 4.9.1), diffuse hair loss (RR 1.00, 95% CI 0.07 to 14.55; N = 30; see Analysis 4.9.2), reversible hypertriglyceridaemia (RR 0.33, 95% CI 0.04 to 2.85; N = 30; see Analysis 4.9.3), withdrawal due to pruritus and burning (RR 3.00, 95% CI 0.13 to 68.26; N = 30; see Analysis 4.9.4), or nausea (RR 0.33, 95% CI 0.01 to 7.58; N = 30; see Analysis 4.9.5).

 

5. NB-UVB compared with selective BB-UVB for chronic plaque psoriasis

 

Primary outcomes

The following two of our primary outcomes were addressed for this comparison.

 
3) Withdrawal due to side-effects

Kirke 2007 found no significant difference between NB-UVB and selective BB-UVB with respect to withdrawals due to adverse events (RR 2.80, 95% CI 0.3 to 25.81; N = 85;  Analysis 5.1); Kirke 2007 also performed ITT analysis and found a similar result (RR 3.00, 95% CI 0.32 to 27.87; N = 100;  Analysis 5.2).

 
4) Clearance rate

Kirke 2007 conducted this comparison in people with CPP. The study found there was no significant difference between the two groups with respect to clearance rate (RR 1.30, 95% CI 0.89 to 1.92; N = 85;  Analysis 5.3). Kirke 2007 also performed ITT analysis and found 28 of 50 (56%) participants who received NB-UVB compared with 20 of 50 (40%) of those who received selective BB-UVB achieved clearance, but the difference did not reach statistical significance (RR 1.40, 95% CI 0.92 to 2.13; N = 100;  Analysis 5.4). Additionally, more participants with skin type III/IV achieved clearance than those with skin type I/II, irrespective of the type of irradiation (odds of clearance = 3.22, 95% CI 1.40 to 7.43).

 

Secondary outcomes

The following four of our secondary outcomes were addressed for this comparison.

 
3) Number of treatments to clearance

Based on Kirke 2007, the median number of treatments to clearance was 28.4 for NB-UVB and 30.4 for selective BB-UVB, but the difference did not reach statistical significance (P = 0.43). In addition, the authors reported that "patients with skin type III/IV cleared faster than patients with skin type I/II," regardless of the type of irradiation.

 
4) Cumulative UV dose to clearance

According to the Kirke 2007 trial conducted in participants with CPP, the median cumulative UV dose to clearance was 40.9 J/cm² for NB-UVB and 39.9 J/cm² for selective BB-UVB, but they did not report the relevant P value or 95% CI.

 
6) Clearance lasting six months

Based on a single outcome event in the study by Kirke 2007, no significant difference was found in clearance lasting six months after treatment completion between those in the NB-UVB and selective BB-UVB groups (5.3% versus 0%; RR 2.10, 95% CI 0.09 to 47.89; N = 32;  Analysis 5.5).

 
15) Adverse events

Kirke 2007 (N = 100) reported the following adverse events: severe erythema (which caused the participants to miss treatments), PMLE, and pruritus ( Analysis 5.6). There were no significant differences between NB-UVB and selective BB-UVB with respect to the incidence of severe erythema (RR 0.67, 95% CI 0.12 to 3.82; see Analysis 5.6.1), PMLE (RR 3.00, 95% CI 0.32 to 27.87; see Analysis 5.6.2), and pruritus (RR 0.20, 95% CI 0.01 to 4.06; see Analysis 5.6.3).

 

6. NB-UVB compared with conventional BB-UVB in people with different types of psoriasis

 

Primary outcomes

No included studies addressed our primary outcomes for this comparison.

 

Secondary outcomes

Only the following two of our secondary outcomes were addressed for this comparison.

 
4) Cumulative UV dose to clearance

Two RCTs (Larko 1989; Storbeck 1993) addressed this outcome; both trials conducted half-body irradiations by left-right comparison. Because there were insufficient data available in Larko 1989, meta-analysis could not be performed. In Storbeck 1993 (N = 10), the mean cumulative UV dose during the study that was statistically significant was 14.68 J/cm² with NB-UVB and 1.427 J/cm² with conventional BB-UVB (MD 13.25, 95% CI 7.11 to 19.39;  Analysis 6.1). By contrast, in Larko 1989, the mean cumulative UV dose was 0.83 J/cm² with NB-UVB and 4.8 J/cm² with conventional BB-UVB (P value or 95% CI was not reported).

 
7) PASI score reduction (before and after treatment)

Storbeck 1993 compared NB-UVB with conventional BB-UVB in 10 participants with different types of psoriasis. The total decrease of the PASI was significantly greater with NB-UVB than with conventional BB-UVB (P < 0.05).

 

7. NB-UVB plus dithranol compared with conventional BB-UVB plus dithranol in people with different types of psoriasis

 

Primary outcomes

No included studies addressed our primary outcomes for this comparison.

 

Secondary outcomes

Only the following two of our secondary outcomes were addressed for this comparison.

 
4) Cumulative UV dose to clearance

Storbeck 1993 also compared NB-UVB plus dithranol with conventional BB-UVB plus dithranol in 13 participants with different types of psoriasis. The mean cumulative UV dose during the study that was statistically significant was 10.93 J/cm² for NB-UVB and 1.3 J/cm² for conventional BB-UVB (MD 9.63, 95% CI 7.09 to 12.17;  Analysis 7.1).

 
7) PASI score reduction (before and after treatment)

Storbeck 1993 compared NB-UVB plus dithranol with conventional BB-UVB plus dithranol in 13 participants with different types of psoriasis. The total decrease of the PASI was statistically significantly greater with NB-UVB than with conventional BB-UVB (P < 0.05).

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Summary of main results

We included 13 RCTs, with 662 participants, in this review, and the main results are listed as follows.

NB-UVB compared with oral PUVA in people with chronic plaque psoriasis: The percentage of participants reaching PASI 75 showed no statistically significant difference between the NB-UVB group and the oral PUVA group, and the ITT analysis gave a similar result. Pooled data from three RCTs indicated that withdrawals due to adverse events were not significantly different between the NB-UVB and the oral PUVA groups, and the ITT analysis gave a similar result. The clearance rate between groups was not consistent within the three included studies because in one, there was no difference between the groups, and in the other two, the clearance rate was statistically significantly in favour of oral PUVA. In one of these two studies, clearance was measured at six months, which was achieved by statistically significantly more participants in the oral PUVA group.

The median number of treatments to clearance was significantly lower in the oral PUVA group compared with NB-UVB, but time to clearance was similar between the two groups. The cumulative UV dose to clearance, relapse rate at six months after treatment, and duration of remission were not significantly different between the groups. Moreover, the participants' QOL in the oral PUVA group was improved more than in the NB-UVB group. Nausea was significantly higher in the oral PUVA group.

Narrow-band UVB compared with bath PUVA in people with chronic plaque psoriasis: The evidence addressing this comparison was not consistent. Two RCTs, which performed left-right body comparison, found no significant difference between the NB-UVB and bath PUVA groups, while another RCT, which performed the comparison between participants, favoured bath PUVA. Intention-to-treat (ITT) analyses did not significantly change the results.

Narrow-band UVB compared with topical PUVA in people with palmoplantar psoriasis: There were no significant differences between NB-UVB treated sides and topical PUVA treated sides in terms of clearance rate, marked improvement rate, and relapse rate. The incidence of palmar hyperpigmentation was statistically significantly higher in the PUVA treated sides.

Retinoid NB-UVB compared with retinoid PUVA in people with chronic plaque or guttate psoriasis: No significant difference was found between re-NB-UVB and re-PUVA with respect to effectiveness, tolerability, and adverse events, irrespective of using the retinoids, etretinate or acitretin, as adjuvant therapy.

Narrow-band UVB compared with selective BB-UVB in people with chronic plaque psoriasis: No significant differences were found between those treated with NB-UVB and those treated with selective BB-UVB in terms of withdrawal due to side-effects, clearance rate, number of treatments to clearance, cumulative UV dose to clearance, and adverse events.

Narrow-band UVB compared with conventional BB-UVB in people with different types of psoriasis: Based on one small RCT, NB-UVB seemed to be more effective than conventional BB-UVB. However, cumulative UV dose to clearance in both groups was not consistent between the two included RCTs.

Narrow-band UVB plus dithranol compared with conventional BB-UVB plus dithranol in people with different types of psoriasis: Based on a small RCT, NB-UVB plus dithranol seemed to be more effective than conventional BB-UVB plus dithranol. However, cumulative UV dose to clearance was higher in the NB-UVB group than the BB-UVB group.

 

Overall completeness and applicability of evidence

Most included RCTs in this review were conducted in adults with psoriasis, but one RCT (Salem 2010) enrolled participants aged more than 13 years, while another RCT (Green 1992) did not report the age of the participants. The results of this review should therefore be applied to adults as the literature regarding the use of phototherapy in paediatric patients with psoriasis is limited (Menter 2010). In addition, these RCTs either did not include or separately reported pregnant women, and in consequence, our review did not contribute to this specific population. However, a recent guideline reported that NB-UVB has been used successfully in pregnant women with psoriasis and "should be considered first-line therapy in pregnant women with plaque and guttate psoriasis who need a systemic approach to treatment" (Menter 2010). Moreover, because most of the included participants suffered from chronic plaque psoriasis (CPP), the evidence for guttate psoriasis and palmoplantar psoriasis was limited, and only one trial (NB-UVB compared with selective BB-UVB) included participants with erythrodermic psoriasis.

In recent years, NB-UVB has replaced conventional BB-UVB as the first-line treatment for psoriasis and has been recommended by US and UK guidelines (Menter 2010; Smith 2009), respectively, or used in clinical practice. In the most recently published guideline (Paul 2012), neither conventional or selective BB-UVB has been mentioned. In this review, we identified only two RCTs (Larko 1989; Storbeck 1993) that compared NB-UVB with conventional BB-UVB; both of the studies were of high risk of bias and small sample sizes. They gave contrasting results with respect to cumulative UV dose to clearance; however, Storbeck 1993 showed that NB-UVB achieved a greater PASI score reduction than conventional BB-UVB. It is noteworthy that many non-RCTs (Coven 1997; Karvonen 1989; Picot 1992; Walters 1999) indicate that NB-UVB is preferable to conventional BB-UVB. The dosage and duration of phototherapy in different trials varied from each other, and no RCT so far has directly compared different dosing strategies and frequency of application.

Most included RCTs applied clearance, minimal residual activity (MRA), PASI, and clinical improvement as the main outcomes, which were subjective and measured by clinicians. Only one RCT (Yones 2006) assessed quality of life, an important outcome for people with psoriasis.

Additionally, the risk of carcinogenesis as a result of phototherapy attracted the greatest concern by the participants and clinicians. Because of the limited duration of follow-up, none of the included RCTs addressed this important issue. A clear relationship between cumulative PUVA exposure and an increased risk of skin cancer had been established (Naldi 2010; Paul 2012; Smith 2009), but there is controversy regarding the risk of skin cancer with NB-UVB or BB-UVB (Weischer 2004). Young 1995 summarised data from murine studies and reported that NB-UVB might be two to three times more carcinogenic per minimal erythema dose (MED) than conventional BB-UVB. However, the following systematic reviews of trials conducted in people with psoriasis (Hearn 2008; Lee 2005; Pasker-de 1999) found that UVB did not increase the risk of skin cancer. Most recently, Archier 2012 found no robust evidence of carcinogenic risk of NB-UVB because of limited prospective studies.

 

Quality of the evidence

The included trials were of varying methodological quality. In general, these trials did not fully follow good practice conduct and reporting guidelines, such as CONSORT (Consolidated Standards of Reporting Trials) (Schulz 2010). First, although all of the studies stated the participants (or half-bodies) were randomly allocated, four of them (Green 1992; Markham 2003; Salem 2010; Storbeck 1993) did not explicitly report the methods of randomisation. Second, allocation concealment was not clearly mentioned in six trials (Markham 2003; Özdemir 2008; Salem 2010; Sezer 2007; Storbeck 1993; Yones 2006), while another trial (Chauhan 2011) explicitly stated that allocation concealment was not performed. Insufficient randomisation or allocation concealment might cause potential selection bias. Third, using clearance, minimal residual activity (MRA), or PASI score as the end points was subjective and relatively imprecise. Thus, it is important to blind the evaluating observers to treatment allocation and treatment supervision. One included trial (Markham 2003) did not apply blinding; the other three trials (Chauhan 2011; Green 1992; Storbeck 1993) did not report whether blinding was used or not. Lack of blinding might cause an overestimation of the effects. It should be noted that different types of phototherapies were performed in different irradiation devices. Besides, PUVA needs use of a photosensitiser (in oral, bath, or topical form), while NB-UVB does not. Hence, it was hard to blind therapists and participants. Fourth, seven of 12 trials had more than 10% dropouts, but only two of them performed ITT analysis, which may be useful to maintain the unbiased group comparison supplied by randomisation. Lack of ITT analysis might lead to potential biases. Last but not least, the sample sizes of these included trials were generally small, which might compromise the value of the results. In a disease with poorly defined treatment outcome measures, small sample size might lead to an underpowered study.

 

Potential biases in the review process

We experienced some limitations during the review process. One published study (Nazari 2005) appeared to meet the inclusion criteria, but we have not yet been able to include or exclude this study. Requests for unpublished data from the authors of some included trials failed, and as a consequence, meta-analysis could not be performed for some outcomes and comparisons. Therefore, the results of this review have to be interpreted with caution.

 

Agreements and disagreements with other studies or reviews

A systematic review (Archier 2012a), which was published most recently, included three RCTs (Gordon 1999; Markham 2003; Yones 2006) that compared NB-UVB with PUVA in people with chronic plaque psoriasis. We included all three of these RCTs in our review. Archier 2012a did not include RCTs that compared NB-UVB with bath PUVA, and the outcomes were slightly different to those in our review: They combined "clearance" with "clearance or MRA" as a single outcome, whereas we reported them separately. In addition, we reported more secondary outcomes; however, the authors drew a similar conclusion, which was that both PUVA and NB-UVB were effective for treating CPP, but oral PUVA was more effective than NB-UVB to "clear psoriasis, with fewer sessions, provided longer lasting clearance, and should therefore still be used in appropriate selected patients".

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

 

Implications for practice

  • Current available evidence is very heterogeneous and has to be interpreted or applied with caution.
  • According to current limited evidence, in people with chronic plaque psoriasis, oral PUVA, compared with NB-UVB, leads to longer lasting clearance, a fewer number of treatments, and higher levels of QOL, but more nausea and a similar relapse rate at six months. The clearance rate between oral PUVA and NB-UVB is contradictory among the included studies. Evidence regarding NB-UVB versus bath PUVA is contradictory. Retinoids with NB-UVB and retinoids with PUVA have a similar effect for treating people with chronic plaque or guttate psoriasis. However, the long-term side-effects of PUVA, especially the potential risk of carcinogenesis, need to be taken into account. In practice, NB-UVB may be more convenient to use since exogenous photosensitiser is not required before phototherapy.
  • Although NB-UVB is considered ineffective for palmoplantar psoriasis in clinical practice, a small included RCT did not detect a statistically significant difference in the efficacy of NB-UVB and topical PUVA in clearing palmoplantar psoriasis. This needs to be investigated in the future.
  • NB-UVB is more effective than or at least equal to selective BB-UVB, irrespective of whether it is combined with dithranol.
  • Evidence regarding NB-UVB and conventional BB-UVB is limited and of poor quality; none of the included studies addressed the primary outcomes in this comparison.

 
Implications for research

This review highlights the need for further high-quality research regarding the use of NB-UVB and PUVA for treating psoriasis. The following key points should be taken into account in future research: a big enough sample size to identify the presumptive difference, strict standardisation of the method of UV irradiation, and appropriate outcomes that matter to people (e.g. quality of life and the cost-effectiveness of the therapy). Good practice guidelines (e.g. CONSORT) must be followed during the process of study design, implementation, and reporting. In addition, prospective studies regarding the carcinogenic risk of NB-UVB therapy are urgently needed.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

The authors appreciate the kind help given by Hywel Williams, Finola Delamere, Elizabeth Doney, and Laura Prescott from the Cochrane Skin Group during the process of drafting the review.

The Cochrane Skin Group editorial base wishes to thank Luigi Naldi who was the Key Editor for this review; Matthew Grainge and Ching-Chi Chi who were the Statistical and Methods Editors, respectively; the clinical referee, Robert Dawe and another clinical referee who wishes to remain anonymous; and the consumer referee, who also wishes to remain anonymous.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
Download statistical data

 
Comparison 1. NB-UVB versus oral PUVA in CPP

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 PASI 751Risk Ratio (M-H, Random, 95% CI)Totals not selected

 2 PASI 75 (ITT analysis)1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 3 Withdrawals due to side-effects3231Risk Ratio (M-H, Random, 95% CI)0.69 [0.19, 2.43]

 4 Withdrawals due to side-effects (ITT analysis)3247Risk Ratio (M-H, Random, 95% CI)0.71 [0.20, 2.54]

 5 Clearance rate1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 6 Clearance rate (ITT analysis)3Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Clearance lasting 6 months1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 8 Time to PASI 751Mean Difference (IV, Random, 95% CI)Totals not selected

 9 Relapse rate at 6 months after treatment completion3172Risk Ratio (M-H, Random, 95% CI)1.08 [0.74, 1.58]

 10 Withdrawals due to poor response1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 11 Adverse events4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    11.1 erythema
3233Risk Ratio (M-H, Random, 95% CI)0.99 [0.47, 2.09]

    11.2 nausea
2131Risk Ratio (M-H, Random, 95% CI)0.12 [0.02, 0.94]

    11.3 pruritus
143Risk Ratio (M-H, Random, 95% CI)0.87 [0.31, 2.43]

    11.4 PMLE
143Risk Ratio (M-H, Random, 95% CI)1.05 [0.16, 6.77]

    11.5 grade 1 erythema
145Risk Ratio (M-H, Random, 95% CI)0.93 [0.68, 1.26]

    11.6 grade 2 erythema
188Risk Ratio (M-H, Random, 95% CI)0.48 [0.13, 1.79]

    11.7 any adverse events
143Risk Ratio (M-H, Random, 95% CI)0.92 [0.40, 2.08]

 
Comparison 2. NB-UVB versus bath PUVA in CPP

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Clearance rate3Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 Studies performing left-right body comparison
270Risk Ratio (M-H, Random, 95% CI)2.03 [0.29, 14.06]

    1.2 Study performing comparison between participants
134Risk Ratio (M-H, Random, 95% CI)0.20 [0.05, 0.79]

 2 Clearance rate (ITT analysis)3Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 Studies performing left-right body comparison
292Risk Ratio (M-H, Random, 95% CI)1.79 [0.46, 6.91]

    2.2 Studies performing comparisons between participants
136Risk Ratio (M-H, Random, 95% CI)0.18 [0.05, 0.71]

 3 PASI score reduction1Mean Difference (IV, Random, 95% CI)Totals not selected

 4 Adverse events3Risk Ratio (M-H, Random, 95% CI)Totals not selected

    4.1 erythema
2Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    4.2 pruritus
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    4.3 grade 1 erythema
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    4.4 grade 2 erythema
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    4.5 grade 3 erythema
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    4.6 folliculitis
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    4.7 any adverse events
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 3. NB-UVB versus topical PUVA in PPP

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Clearance rate1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 2 Clearance rate (ITT analysis)1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 3 Relapse at 9 weeks after treatment completion1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 4 Marked improvement1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 5 Adverse events1Risk Ratio (M-H, Random, 95% CI)Totals not selected

    5.1 palmar hyperpigmentation
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 4. NB-UVB plus retinoid versus PUVA plus retinoid in chronic plaque or guttate psoriasis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 PASI1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 2 PASI 75 (ITT analysis)1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 3 Clearance rate282Risk Ratio (M-H, Random, 95% CI)0.91 [0.78, 1.07]

 4 Clearance rate (ITT analysis)290Risk Ratio (M-H, Random, 95% CI)0.93 [0.79, 1.10]

 5 Relapse at 6 months after treatment completion1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 6 Clinical improvement1Risk Ratio (M-H, Random, 95% CI)Totals not selected

    6.1 Marked improvement (50% to 75% improvement in PASI, ITT analysis)
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    6.2 Moderate improvement (25% to 50% improvement in PASI, ITT analysis)
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    6.3 Slight improvement (5% to 25% improvement in PASI, ITT analysis)
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    6.4 No improvement (< 5% improvement in PASI, ITT analysis)
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 7 Tolerability assessed as good or very good by observers (ITT analysis)1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 8 Tolerability assessed as good or very good by participants (ITT analysis)1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 9 Adverse events2Risk Ratio (M-H, Random, 95% CI)Totals not selected

    9.1 erythema
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    9.2 diffuse hair loss
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    9.3 reversible hypertriglyceridaemia
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    9.4 withdrawal due to pruritus and burning
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    9.5 nausea
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 5. NB-UVB versus selective BB-UVB in CPP

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Withdrawal due to side-effects1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 2 Withdrawals due to side-effects (ITT analysis)1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 3 Clearance rate1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 4 Clearance rate (ITT analysis)1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 5 Clearance lasting 6 months1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 6 Adverse events1Risk Ratio (M-H, Random, 95% CI)Totals not selected

    6.1 severe erythema
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    6.2 PMLE
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    6.3 pruritus
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 6. NB-UVB versus conventional BB-UVB in different types of psoriasis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Cumulative UV dose during the study1Mean Difference (IV, Random, 95% CI)Totals not selected

 
Comparison 7. NB-UVB plus dithranol versus conventional BB-UVB plus dithranol in different types of psoriasis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Cumulative UV dose during the study1Mean Difference (IV, Random, 95% CI)Totals not selected

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Appendix 1. Skin Group Specialised Register search strategy

(psoria* or “palmoplantar* pustulosis” or “pustulosis palmaris et plantaris” or “pustulosis and palms and soles”) and (Phototherap* or Photochemotherap* or “light therap*” or “photodynamic therap*” or “photoradiation therap*” or Ultraviolet or BBUVB or NBUVB or “BB-UVB” or “NB-UVB” or “broad band uvb” or “broad band ultraviolet b” or “narrow band uvb” or “narrow band ultraviolet b” or psoralen or PUVA)

 

Appendix 2. CENTRAL (Cochrane Library) search strategy

#1 (psoria*):ti,ab,kw or (palmoplantar* pustulosis):ti,ab,kw or (pustulosis palmaris et plantaris):ti,ab,kw or (pustulosis and palms and soles):ti,ab,kw
#2 MeSH descriptor Psoriasis, this term only
#3 (#1 OR #2)
#4 MeSH descriptor Phototherapy, this term only
#5 MeSH descriptor Ultraviolet Therapy, this term only
#6 MeSH descriptor PUVA Therapy, this term only
#7 MeSH descriptor Photochemotherapy, this term only
#8 (photodynamic therap*):ti,ab,kw or (phototherap*):ti,ab,kw or (photochemotherap*):ti,ab,kw or (puva):ti,ab,kw or (ultraviolet):ti,ab,kw
#9 (light therap*):ti,ab,kw or (photoradiation therap*):ti,ab,kw or (BBUVB):ti,ab,kw or (NBUVB):ti,ab,kw or (BB-UVB or NV-UVB):ti,ab,kw
#10 (broad band uvb):ti,ab,kw or (broad band ultraviolet b):ti,ab,kw or (narrow band uvb):ti,ab,kw or (narrow band ultraviolet b):ti,ab,kw
#11 (psoralen ultraviolet a):ti,ab,kw or (psoralen uva):ti,ab,kw
#12 (#4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11)
#13 (#3 AND #12)

 

Appendix 3. MEDLINE (OVID) search strategy

1. exp Psoriasis/ or psoria$.mp.
2. palmoplantar$ pustulosis.mp.
3. pustulosis palmaris et plantaris.mp.
4. (pustulosis and palms and soles).mp.
5. 1 or 2 or 3 or 4
6. exp Phototherapy/
7. exp Ultraviolet Therapy/
8. exp PUVA Therapy/
9. exp Photochemotherapy/
10. photodynamic therap$.mp.
11. phototherap$.mp.
12. photochemotherap$.mp.
13. puva.mp.
14. ultraviolet.mp.
15. light therap$.mp.
16. photoradiation therap$.mp.
17. BBUVB.mp.
18. NBUVB.mp.
19. BB-UVB.mp.
20. NB-UVB.mp.
21. broad band uvb.mp.
22. broad band ultraviolet b.mp.
23. narrow band uvb.mp.
24. narrow band ultraviolet b.mp.
25. psoralen ultraviolet a.mp.
26. psoralen uva.mp.
27. or/6-26
28. randomized controlled trial.pt.
29. controlled clinical trial.pt.
30. randomized.ab.
31. placebo.ab.
32. clinical trials as topic.sh.
33. randomly.ab.
34. trial.ti.
35. 28 or 29 or 30 or 31 or 32 or 33 or 34
36. (animals not (human and animals)).sh.
37. 35 not 36
38. 5 and 27 and 37

 

Appendix 4. EMBASE (OVID) search strategy

1. photodynamic therap$.ti,ab.
2. phototherap$.ti,ab.
3. photochemotherap$.ti,ab.
4. puva.ti,ab.
5. ultraviolet.ti,ab.
6. light therap$.ti,ab.
7. photoradiation therap$.ti,ab.
8. BBUVB.ti,ab.
9. NBUVB.ti,ab.
10. BB-UVB.ti,ab.
11. NB-UVB.ti,ab.
12. broad band uvb.ti,ab.
13. broad band ultraviolet b.ti,ab.
14. narrow band uvb.ti,ab.
15. narrow band ultraviolet b.ti,ab.
16. psoralen ultraviolet a.ti,ab.
17. psoralen uva.ti,ab.
18. exp phototherapy/
19. exp PUVA/
20. exp photochemotherapy/
21. or/1-20
22. exp PSORIASIS/
23. psoria$.ti,ab.
24. palmoplantar$ pustulosis.ti,ab.
25. pustulosis palmaris et plantaris.ti,ab.
26. (pustulosis and palms and soles).ti,ab.
27. 22 or 23 or 24 or 25 or 26
28. random$.mp.
29. factorial$.mp.
30. (crossover$ or cross-over$).mp.
31. placebo$.mp. or PLACEBO/
32. (doubl$ adj blind$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
33. (singl$ adj blind$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
34. (assign$ or allocat$).mp.
35. volunteer$.mp. or VOLUNTEER/
36. Crossover Procedure/
37. Double Blind Procedure/
38. Randomized Controlled Trial/
39. Single Blind Procedure/
40. 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39
41. 21 and 27 and 40

 

Appendix 5. CNKI search strategy (in Chinese)

#1 psoriasis/exp

#2 psoriasis or "palmoplantar pustulosis"

#3 #1 or #2

#4 Phototherapy/exp

#5 Ultraviolet Therapy/exp

#6 PUVA Therapy/exp

#7 Photochemotherapy/exp

#8 photodynamic therapy

#9 phototherapy

#10 photochemotherapy

#11 photoradiation therapy

#12. broad band ultraviolet

#13 narrow band ultraviolet

#14 psoralen ultraviolet

#15 #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14

#16 #3 and #15

 

Appendix 6. CBM search strategy (in Chinese)

#1 psoriasis/exp

#2 psoriasis or "palmoplantar pustulosis"

#3 #1 or #2

#4 Phototherapy/exp

#5 Ultraviolet Therapy/exp

#6 PUVA Therapy/exp

#7 Photochemotherapy/exp

#8 photodynamic therapy

#9 phototherapy

#10 photochemotherapy

#11 photoradiation therapy

#12. broad band ultraviolet

#13 narrow band ultraviolet

#14 psoralen ultraviolet

#15 #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14

#16 #3 and #15

 

Appendix 7. Trial registers and OpenGray database search strategy

(psoriasis or palmoplantar pustulosis) and (phototherapy or ultraviolet therapy or photochemotherapy or photoradiation therapy or PUVA or NB-UVB or BB-UVB or NBUVB or BBUVB)

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Last assessed as up-to-date: 8 August 2013.


DateEventDescription

23 December 2014AmendedThere were no ongoing studies listed in the last published review, and a search of MEDLINE and PubMed in December 2014 did not find any relevant results. Thus, an update has not been considered necessary at this time. Our Trials Search Co-ordinator will run a new search in 2015 to re-assess whether an update is needed.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

Ming Yang and Xiaomei Chen are joint first authors as they contributed equally to this review.
Min Zhang was the contact person with the editorial base, co-ordinated contributions from the co-authors, and wrote the final draft of the review.
Xiaomei Chen, Yan Cheng, and Ming Yang screened papers against eligibility criteria.
Xiaomei Chen and Yan Cheng appraised the quality of the papers.
Xiaomei Chen and Ming Yang extracted data for the review and sought additional information about papers.
Ming Yang entered data into RevMan.
Ming Yang, Xiaomei Chen, and Guanjian Liu analysed and interpreted data.
Xiaomei Chen and Ming Yang worked on the methods sections.
Xiaomei Chen and Min Zhang drafted the clinical sections of the background.
Yan Cheng was the consumer co-author and checked the review for readability and clarity, as well as ensuring outcomes are relevant to consumers.
Min Zhang is the guarantor of the update.

Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health, UK.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms
 

Internal sources

  • Dermatology Department, West China Hospital of Sichuan University, China.

 

External sources

  • The National Institute for Health Research (NIHR), UK.
    The NIHR, UK, is the largest single funder of the Cochrane Skin Group.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

We added some useful information to the background regarding the categories of psoriasis, and the treatments PUVA and BB-UVB. These additional pieces of information might help readers understand the relevance of the contents more easily.

We moved one of our prespecified secondary outcomes, namely 'Percentage of participants who achieved complete clearance in the clinician's opinion', to a primary outcome, and we also renamed it 'Clearance rate'. The reason we did this is because 'clearance rate' is an important outcome for both clinicians and people with psoriasis, and during the process of working on the review, we identified some studies that reported 'complete clearance' and 'minimal residual activity (MRA)' as an independent outcome named 'clearance', and in our opinion, it was a reasonable change to make.

We also added further outcomes to our secondary outcomes, which we identified while working on the review, and we thought they might be valuable for users to make an optimal treatment choice.

In the protocol, we planned to search for information regarding adverse events from non-RCTs. However, we did not carry out these further searches for three reasons:

  1. The included RCTs revealed that phototherapy is generally well-tolerated although some mild adverse events might exist.
  2. The included RCTs had paid much attention to the adverse events.
  3. According to the Cochrane Handbook for Systematic Reviews of Interventions, it is reasonable to use either identical or different eligibility criteria for selecting studies that address beneficial effects and adverse effects.

In addition, in the protocol, we planned to use an alpha of 0.05 for the Chi² test. However, during the process of drafting, we found that the number of trials included in meta-analyses was few. In this case, we used a P value of 0.10 for the Chi² test.

 

Notes

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
  18. Index terms

There were no ongoing studies listed in the last published review, and a search of MEDLINE and PubMed in December 2014 did not find any relevant results. Thus, an update has not been considered necessary at this time. Our Trials Search Co-ordinator will run a new search in 2015 to re-assess whether an update is needed.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Chauhan 2011 {published data only}
Dawe 2003 {published data only}
Gordon 1999 {published data only}
  • Gordon PM, Diffey BL, Farr PM. A comparison of narrow-band TL01 phototherapy and psoralen-UVA photochemotherapy for psoriasis [Summary]. British Journal of Dermatology 1997;137(Suppl 50):15. [DOI: 10.1111/j.1365-2133.1997.tb01879.x]
  • Gordon PM, Diffey BL, Matthews JN, Farr PM. A randomized comparison of narrow-band TL-01 phototherapy and PUVA photochemotherapy for psoriasis. Journal of the American Academy of Dermatology 1999;41(5 Pt 1):728-32. [MEDLINE: 10534635]
Green 1992 {published data only}
Kirke 2007 {published data only}
  • Kirke SM, Lowder S, Lloyd J, Matthews JN, Farr PM. A randomized comparison of selective broadband UVB and narrowband UVB in the treatment of psoriasism [Abstract RF-4]. The 85th BAD Annual Meeting 5-8th July 2005, Glasgow, UK. British Journal of Dermatology 2005;153(Suppl 1):10.
  • Kirke SM, Lowder S, Lloyd JJ, Diffey BL, Matthews JN, Farr PM. A randomized comparison of selective broadband UVB and narrowband UVB in the treatment of psoriasis. Journal of Investigative Dermatology 2007;127(7):1641-6. [MEDLINE: 17380117]
Larko 1989 {published data only}
Markham 2003 {published data only}
  • Markham T, Rogers S, Collins P. A comparison of oral 8-methoxypsoralen PUVA and narrowband UVB (TL-OI) phototherapy in the management of chronic plaque psoriasis [Summary]. British Journal of Dermatology 2001;145(Suppl 59):25. [DOI: 10.1046/j.1365-2133.2001.012ff.x]
  • Markham T, Rogers S, Collins P. Narrowband UV-B (TL-01) phototherapy vs oral 8-methoxypsoralen psoralen-UV-A for the treatment of chronic plaque psoriasis. Archives of Dermatology 2003;139(3):325-8. [MEDLINE: 12622624]
Özdemir 2008 {published data only}
  • Özdemir M, Engin B, Baysal I, Mevlitoglu I. A randomized comparison of acitretin-narrow-band TL-01 phototherapy and acitretin-psoralen plus ultraviolet A for psoriasis. Acta Dermato-Venereologica 2008;88(6):589-93. [MEDLINE: 19002344]
Salem 2010 {published data only}
Sezer 2007 {published data only}
Snellman 2004 {published data only}
  • Snellman E, Klimenko T, Rantanen T. Randomized half-side comparison of narrowband UVB and trimethylpsoralen bath plus UVA treatments for psoriasis. Acta Dermato-Venereologica 2004;84(2):132-7. [MEDLINE: 15206693]
Storbeck 1993 {published data only}
  • Storbeck K, Holzle E, Schurer N, Lehmann P, Plewig G. Narrow-band UVB (311 nm) versus conventional broad-band UVB with and without dithranol in phototherapy for psoriasis. Journal of the American Academy of Dermatology 1993;28(2 Pt 1):227-31. [MEDLINE: 8432920]
Yones 2006 {published data only}
  • Yones SS, Garibadinos T, Seed P, Csaszar M, Hawk J. A prospective randomized double blind trial of the efficacy of narrowband UVB (TL01) phototherapy and psoralen photochemotherapy (PUVA) in the treatment of chronic plaque psoriasis (CPP) [Abstract FC11.10]. 14th Congress of the European Academy of Dermatology and Venereology, London, UK. 12-15th October 2005. Journal of the European Academy of Dermatology & Venereology 2005;19(Suppl 2):47. [DOI: 10.1111/j.1468-3083.2005.01310.x]
  • Yones SS, Palmer RA, Garibaldinos TT, Hawk JL. Randomized double-blind trial of the treatment of chronic plaque psoriasis: efficacy of psoralen-UV-A therapy vs narrowband UV-B therapy. Archives of Dermatology 2006;142(7):836-42. [MEDLINE: 16847198]

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Boer 1984 {published data only}
Coven 1997 {published data only}
  • Coven TR, Burack LH, Gilleaudeau R, Keogh M, Ozawa M, Krueger JG. Narrowband UV-B produces superior clinical and histopathological resolution of moderate-to-severe psoriasis in patients compared with broadband UV-B. Archives of Dermatology 1997;133(12):1514-22. [MEDLINE: 9420535]
Dayal 2010 {published data only}
  • Dayal S, Mayanka, Jain VK. Comparative evaluation of NBUVB phototherapy and PUVA photochemotherapy in chronic plaque psoriasis. Indian Journal of Dermatology, Venereology & Leprology 2010;76(5):533-7. [MEDLINE: 20826993]
Malhotra 2010 {published data only}
  • Malhotra V. Comparative efficacy of photochemotherapy and narrow band ultraviolet B radiation in the treatment of severe plaque-type psoriasis [Summary PD-9]. Conference: 90th Annual Meeting of the British Association of Dermatologists Manchester United Kingdom. Conference Start: 20100706 Conference End: 20100708. British Journal of Dermatology 2010;163(Suppl 1):134-5. [EMBASE: 70234375]
Roson 2005 {published data only}
  • Roson E, Garcia-Doval I, Florez A, Cruces M. Comparative study of the treatment of psoriasis plaques with PUVA baths and narrow-band UVA (311 NM). Actas Dermo-Sifiliograficas 2005;96(6):371-5. [MEDLINE: 16476256]
Tanew 1996 {published data only}
  • Tanew A, Fijan S, Honigsmann H. Halfside comparison study on narrow-band UV-B phototherapy versus photochemotherapy (PUVA) in the treatment of severe psoriasis [Abstract 212]. 1996 Annual Meeting Society for Investigative Dermatology . Journal of Investigative Dermatology 1996;106(4):841. [DOI: 10.1111/1523-1747.ep12346478]
Ul 2005 {published data only}
  • Ul Bari A, Iftikhar N, Ber Rahman S. Comparison of PUVA and UVB therapy in moderate plaque psoriasis. Journal of Pakistan Association of Dermatologists 2005;15(1):26-31. [EMBASE: 2006474827]

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Nazari 2005 {published data only}
  • Nazari S, Ozarmagan G, Erzengin D, Akar U. A randomized comparison of narrow-band UVB phototherapy and PUVA photochemotherapy in the management of plaque-type psoriasis [Psoriasiste PUVA ve dar bant UVB tedavilerinin klinik etkinliklerinin karsilastirilmasi]. Turkderm Deri Hastaliklari ve Frengi Arsivi 2005;39(2):103-8. [EMBASE: 2006204570]

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
Anderson 1984
Archier 2012
Archier 2012a
Ashworth 1989
  • Ashworth J, Kahan MC, Breathnach SM. PUVA therapy decreases HLA-DR+ CDIa+ Langerhans cells and epidermal cell antigen-presenting capacity in human skin, but flow cytometrically-sorted residual HLA-DR+ CDIa+ Langerhans cells exhibit normal alloantigen-presenting function. British Journal of Dermatology 1989;120(3):329-39. [MEDLINE: 2469456]
Aubin 1998
Aufiero 2006
Boer 1980
Boffetta 2001
Borroni 1991
  • Borroni G, Zaccone C, Vignati G, Fietta A, Gatti M, Brazzelli V, et al. Lymphopenia and decrease in the total number of circulating CD3+ and CD4+ T cells during 'long-term' PUVA treatment for psoriasis. Dermatologica 1991;183(1):10-4. [MEDLINE: 1837524]
Braun 2000
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Brenner 1983
Coven 1999
De Gruijl 1996
  • De Gruijl FR. Long-term side effects and carcinogenesis risk in UVB therapy. In: Honigsmann H, Jori G, Young AR editor(s). The Fundamental Bases of Photo-therapy. Milan, Italy: OEMF, 1996:153-70.
De Korte 2004
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Finlay 1994
Fischer 1976
Fitzpatrick 1988
Gelfand 2003
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Gelfand 2006
Godar 2003
Green 1988
Griffiths 1996
Hannuksela-Svahn 2000
Hearn 2008
Higgins 2011
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Hofer 2006
Honigsmann 1977
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Ibbotson 2004
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Jensen 2010
Karvonen 1989
Kozenitzky 1992
  • Kozenitzky L, David M, Sredai B, Albeck M, Shohat B. Immunomodulatory effects of AS101 on interleukin-2 production and T-lymphocyte function of lymphocytes treated with psoralens and ultraviolet A. Photodermatology, Photoimmunology & Photomedicine 1992;9(1):24-8. [MEDLINE: 1390119]
Lauharanta 1997
Lebwohl 2003
Lee 2005
Lowe 1997
Menter 2010
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Morison 1995
Morison 1998
Naldi 2010
Neuner 1994
Parrish 1981
Pasker-de 1999
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Paul 2012
Picot 1992
Saurat 1999
Schulz 2010
Smith 2009
Stern 1988
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Tahir 2004
  • Tahir R, Mujtaba G. Comparative efficacy of psoralen - UVA photochemotherapy versus narrow band UVB phototherapy in the treatment of psoriasis. Journal of the College of Physicians & Surgeons - Pakistan 2004;14(10):593-5. [MEDLINE: 15456547]
van Weelden 1988
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Walters 1999
  • Walters IB, Burack LH, Coven TR, Gilleaudeau P, Krueger JG. Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris. Journall of American Academic Dermatology 1999;40(6 Pt 1):893-900. [MEDLINE: 10365919]
Weischer 2004
  • Weischer M, Blum A, Eberhard F, Rocken M, Berneburg M. No evidence for increased skin cancer risk in psoriasis patients treated with broadband or narrowband UVB phototherapy: a first retrospective study. Acta Dermato-Venereologica 2004;84(5):370-4. [MEDLINE: 15370703]
Young 1995
Zanolli 2000
  • Zanolli MD, Camisa C, Feldman S, Gulliver W, Menter A. Psoriasis: the high notes on current treatment. Program of the American Academy of Dermatology. Nashville, TN, August 5, 2000.