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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, Department of Geriatrics, 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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Characteristics of included studies [ordered by study ID]
Chauhan 2011

MethodsThis was a randomised controlled trial conducted in India


ParticipantsInclusion criteria of the trial

  • People with Fitzpatrick skin types IV and V (Fitzpatrick 1988) who had plaque-type psoriasis with involvement of more than 20% body surface area (BSA)


Exclusion criteria of the trial

  • Those normally recommended for PUVA or NB-UVB
  • Those with pustular psoriasis or erythroderma


51 participants were recruited; 43 of them completed the study

Age: 35.7 ± 13.1 years

Men: 35

Women: 8


InterventionsGroup 1

  • NB-UVB 3 times weekly on nonconsecutive days. Following a standard starting dose of 280 mJ/cm², the UV dose was increased by 20% at each subsequent visit, depending on erythema and any subjective symptoms


Group 2

  • PUVA 3 times weekly on nonconsecutive days. The initial dose depended on skin type (2.0 J/cm² for skin type IV, and 2.5 J/cm² for skin type V). The dosage of UVA was increased by 1 to 1.5 J/cm² at every second visit. Participants also received oral methoxsalen tablets 0.6 mg/kg body weight followed by UVA exposure 2 hours later


In both groups, no concomitant treatment was allowed except for emollients and antihistamines

If no improvement in disease severity was observed after treatment for 6 weeks, the treatment was stopped and considered a treatment failure. The treatment protocol was continued until a participant achieved > 75% reduction in PASI or for up to 4 months, whichever was earlier


Outcomes
  1. Participants reached PASI 75
  2. Time taken to achieve PASI 75
  3. Relapse rate within 6 months after treatment completion
  4. Total UV dose required
  5. Adverse events


NotesThe trial included participants with skin types IV and V. In addition, the authors defined the following outcomes but did not report them: no response rate, mild improvement rate, and moderate improvement rate


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe participants were randomly assigned using a computer-generated random number table

Allocation concealment (selection bias)High riskQuote: "The random allocation list was not concealed"

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskThe authors did not clearly state whether blinding was used or not

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThe authors did not clearly state whether blinding was used or not

Incomplete outcome data (attrition bias)
All outcomes
High risk8 (16%) participants discontinued the trial. When assessing "time to relapse", only 29 (57%) participants were available for analysis

Selective reporting (reporting bias)High riskThe following outcomes were described in the methods section, but were not reported in the results section: no response rate, mild improvement rate, and moderate improvement rate

Other biasUnclear riskInsufficient information was available

Dawe 2003

MethodsThis was a randomised, controlled, single-blind, within-patient, side-to-side comparison trial conducted in the UK from September 1996 to May 1999


ParticipantsInclusion criteria of the trial

  • People with chronic plaque psoriasis


Exclusion criteria of the trial

  • Age < 18 years
  • A history of skin cancer or solar keratoses
  • Phototherapy, PUVA, or systemic therapy for psoriasis within the preceding 3 months


28 participants were included; 18 of them completed the study

Age: 22 to 71 years

Men: 17

Women: 11


InterventionsThe randomisation was performed within participants. Each half-body (sagittal plane) was treated independently. The side allocated to NB-UVB therapy was treated first, followed by bath water application of trimethoxypsoralen (TMP), and later on, UVA irradiation to the other side of the body. Hence, the unit of analysis was half of the participant's body

Group 1

  • NB-UVB 3 times weekly. The starting dose was 70% of minimal erythemal dose (MED), then the UV dose was increased by 20% (reducing to 10%) at each subsequent visit. The maximum exposure dose stopping treatment was 2066 mJ/cm²


Group 2

  • Bath PUVA 2 times weekly. The starting dose was 40% of the minimal phototoxic dose (MPD), then the UV dose was increased by 20% (reducing to 10%) at each subsequent visit. The maximum exposure dose stopping treatment was 15 J/cm²


Treatment was stopped when the participant was clear or after the fourth exposure following first documentation of minimal residual activity (MRA), whichever was earlier. Moreover, the authors set a maximum limit of 30 treatments to either side


Outcomes
  1. The median treatments to achieve clearance of the lesions or minimal residual activity (MRA)
  2. The median time to achieve clearance of the lesions or MRA
  3. Percentage of participants who achieved clearance of the lesions or MRA
  4. The median fall in psoriasis severity score
  5. Adverse events


NotesLoss to follow up was very high (36%) in this trial. In addition, randomisation was performed within participants. The unit of analysis was the "half-body". Furthermore, only participants with skin phototype I to III participated in this trial


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskA statistical book was consulted for a "random number"

Allocation concealment (selection bias)Low riskThe random number was held by a departmental secretary who was not directly involved in the trial

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants and nurse phototherapists in this study were not blinded

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe observer was masked

Incomplete outcome data (attrition bias)
All outcomes
High risk10 (36%) participants were lost to follow up, although it reported findings for ITT analysis (full analysis set) and per-protocol analysis set

Selective reporting (reporting bias)Low riskAll outcomes described in the methods section were reported in the results of the trial report. In addition, the mean, 95% CI, and P value were all reported for the main outcomes

Other biasHigh riskThe included participants were atypical of the psoriasis participant population as a whole, because they were more likely to have been treated with PUVA before and appeared to have more treatment-resistant psoriasis than non-participants. In other words, the baseline in both groups seemed to be unequal. In addition, the study withdrawal was extremely high, and withdrawal of 1 body-half for any reason inevitably caused withdrawal of the other half. Third, each participant received both treatment regimens, so the treatment to 1 side might have affected the other. All of these pitfalls might have induced other bias

Gordon 1999

MethodsThis was a single-blind, parallel, randomised, controlled trial conducted in the UK from July 1996 to September 1997


ParticipantsInclusion criteria of the trial

  • People with chronic plaque psoriasis, Fitzpatrick skin type I to IV


Exclusion criteria of the trial

  • People receiving other systemic therapy for psoriasis, such as acitretin or methotrexate
  • People who received any form of UV therapy within the preceding 6 months
  • People who received any therapy other than emollient in the 4 weeks before beginning treatment


100 participants were included; 94 participants completed the study

Age: 43.3 ± 12.9 years in the NB-UVB group; 41.0 ± 11.2 in the PUVA group

Gender: not reported


InterventionsGroup 1

  • NB-UVB twice weekly. The initial dose was 70% of the MED. Weekly dose increments were used, starting with 30% to 40%, reducing stepwise to 5% to 10% by the sixth week


Group 2

  • Oral PUVA twice weekly. The initial dose ranged from 1 to 2.5 J/cm² and was chosen according to previous PUVA history, skin type, and experience of sunburn. The dose was then increased if tolerated in approximately equal steps to the previously determined MPD, given on the third and fourth treatment days or to a maximum of 6 J/cm². Weekly dose increments were used, starting with 40%, reducing stepwise to 10% by the sixth week. Oral methoxsalen was given using a dosing system on the basis of BSA (25 mg/m²)


Participants whose skin failed to improve significantly after 16 treatments were withdrawn from the trial


Outcomes
  1. Clearance of psoriasis
  2. Number of exposures for clearance
  3. Cumulative UV dose for clearance
  4. Relapse rate at 3 and 6 months after treatment completion
  5. Adverse events


NotesNB-UVB was performed twice weekly in this trial; this regimen might not be optimal, as there was evidence that NB-UVB might be more effective when given more frequently. In addition, the trial included participants with skin type I to IV


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Treatment allocation was based on randomised permuted blocks within strata"

Allocation concealment (selection bias)Low riskSealed envelopes were used

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants and phototherapists were not blinded

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Assessments were made by a clinician, unaware of the treatment allocation"

Incomplete outcome data (attrition bias)
All outcomes
Low riskOnly 6 (6%) participants were lost to follow up

Selective reporting (reporting bias)Unclear riskInsufficient information was available

Other biasUnclear riskInsufficient information was available

Green 1992

MethodsThis was a parallel, randomised, controlled trial conducted in the UK


ParticipantsInclusion criteria of the trial

  • People with extensive chronic plaque or guttate psoriasis if they either 1) failed to respond to UVB or PUVA previously, 2) had experienced rapid relapse following UVB or PUVA, or 3) had a high cumulative PUVA dose (> 1000 J/cm²)


Exclusion criteria of the trial

  • Coexistent hepatic or renal malfunction
  • PUVA, methotrexate, or retinoid therapy in the preceding 2 months
  • A history of Ischaemic heart disease, hyperlipidaemia, or cutaneous malignancy
  • Fertile women without contraception


45 participants were included and completed the study

Age: not reported

Men: 25

Women: 20


InterventionsGroup 1

  • NB-UVB 3 times weekly. The initial dose was 70% of MED; thereafter, incremental increases of 40% were chosen to achieve slight erythema with each subsequent dose. Once the clearance or MRA was achieved, treatment was continued for a further 2 weeks


Group 2

  • NB-UVB and retinoid. Etretinate was applied at a dose of 1 mg/kg unless adverse events necessitated a dose reduction. Pretreatment with etretinate for 2 weeks was followed by NB-UVB 3 times weekly in combination with etretinate. Once the clearance or MRA was achieved, treatment was continued for a further 2 weeks


Group 3

  • PUVA and retinoid. Pretreatment with etretinate (1 mg/kg per day) for 2 weeks was followed by a combination of etretinate and PUVA. PUVA included oral 8-methoxypsoralen (0.6 mg/kg twice weekly) plus UVA irradiation. The initial dose was 0.5 J/cm², with increments of 0.5 to 1.0 J/cm² weekly. Once the clearance or MRA was achieved, treatment was continued for a further 2 weeks


Outcomes
  1. Participants reached clearance or MRA
  2. Mean number of treatments to achieve clearance or MRA
  3. Time to achieve clearance or MRA
  4. Mean total exposure dose to achieve clearance or MRA
  5. Relapse rate within 6 months after treatment completion
  6. Adverse events


NotesThis trial included 3 interventions. According to our preliminary protocol, only data regarding NB-UVB and retinoids versus PUVA and retinoids were extracted and applied in this review. In addition, the trial did not report the participants' skin type


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Patients were randomised"

Comment: The detail of randomisation was not clear

Allocation concealment (selection bias)Low risk"A sealed code kept in the pharmacy" was used

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information was available

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information was available

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo participant was lost to follow up

Selective reporting (reporting bias)High riskThe authors only reported mean and range in main outcomes, and relevant P value or 95% CI were not stated in the study. We failed to make contact with them to get more information

Other biasUnclear riskInsufficient information was available

Kirke 2007

MethodsThis was a randomised, controlled, single-blind, parallel trial conducted in the UK from May 2003 to June 2005


ParticipantsInclusion criteria of the trial

  • People with plaque-type psoriasis


Exclusion criteria of the trial

  • Younger than 18 years
  • Those who received phototherapy or systemic agents for psoriasis in the preceding 3 months


100 participants were included in the study; 85 of them completed the study

Age: 19 to 77 years

Men: 45

Women: 55


InterventionsGroup 1

  • NB-UVB 3 times weekly


Group 2

  • Selective BB-UVB 3 times weekly


The initial treatment dose was 70% of the MED, and the dose was increased after alternate treatments by 40%, decreasing stepwise to 5% by the 18th treatment. If erythema developed during treatment, depending on the severity, planned dose increments were postponed or treatments were missed until the erythema resolved. Participants who cleared, and those who did not clear but received at least 16 exposures, were judged to have completed the trial

Adjunctive therapy was restricted to emollients


Outcomes
  1. The number of treatments to clearance
  2. Cumulative UV dose for clearance
  3. Clearance rate
  4. PASI score for non-clearing participants
  5. Continued clearance at 3 or 6 months after treatment completion
  6. Adverse events


NotesThe trial included participants with skin type I to IV


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskTreatment allocation was "based on randomised permuted blocks within strata"

Allocation concealment (selection bias)Low riskQuote: "Treatment allocation used opaque, sequentially numbered, sealed envelopes"

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants and nurse phototherapists were not blinded

Blinding of outcome assessment (detection bias)
All outcomes
Low riskObservers were masked

Incomplete outcome data (attrition bias)
All outcomes
Low risk15 (15%) participants discontinued the study. The reason for discontinuation was clearly stated in the study, and the withdrawals were distributed equally between the groups. Furthermore, ITT analysis was used

Selective reporting (reporting bias)Low riskAll outcomes described in the protocol were reported in the results of the trial report. In addition, the mean, 95% CI, and P value were all reported for the main outcomes

Other biasUnclear riskInsufficient information was available

Larko 1989

MethodsThis was a randomised, double-blind, within-patient trial conducted in Sweden


ParticipantsInclusion criteria of the trial

  • People with psoriasis


Exclusion criteria of the trial

  • The exclusion criteria was not reported


29 participants were included in this study. The author did not report how many participants completed this study

The median age was 35 (range from 19 to 76 years)

Men: unclear

Women: unclear


InterventionsThe NB-UVB (TL-01) and conventional BB-UVB (TL-12) treatments were assigned randomly to the left or right side. The maximum irradiation time was set to 30 minutes

Group 1

  • NB-UVB, 0.07 mW/cm², 3 to 5 times per week, for a maximum of 8 weeks


Group 2

  • Conventional BB-UVB, 0.7 mW/cm², 3 to 5 times per week, for a maximum of 8 weeks


Adjunctive therapy was restricted to emollients


Outcomes
  1. Mean cumulative UV dose
  2. Scores of symptoms


NotesThis was a left-right comparison study. In addition, the trial did not report the participants' skin type


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskAlthough the left and right sides of the participants received NB-UVB (TL-01) or conventional BB-UVB (TL-12), respectively in "randomized order", the method of randomisation was not clearly described

Allocation concealment (selection bias)Unclear riskInsufficient information was available

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information was available, although the author stated that this study was a "double-blind" study in the abstract. The method of blinding was not addressed in the report

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information was available, although the author stated that this study was a "double-blind" study in the abstract. The method of blinding was not addressed in the report

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThe author did not report relevant information

Selective reporting (reporting bias)High riskThe author did not report a P value or 95% CI for most of the outcomes

Other biasHigh riskThe unit of analysis was the half-body. Withdrawal of 1 body-half for any reason inevitably caused withdrawal of the other half. In addition, each participant received both treatment regimens; the treatment to 1 side might have affected the other. All of these pitfalls might have induced other bias

Markham 2003

MethodsThis was an open-label, parallel, randomised, controlled trial conducted in Ireland from January 1999 to June 2000


ParticipantsInclusion criteria of the trial

  • People with chronic plaque psoriasis who had at least 8% psoriasis extent on the truck and limbs and had not received any specific antipsoriatic treatment within 2 weeks prior to the study or phototherapy treatment for 4 months beforehand
  • People with skin types I, II, or III


Exclusion criteria of the trial

  • Younger than 16 years of age
  • Pregnant or lactating
  • Renal or hepatic disease
  • Active systematic therapy within the previous 8 weeks for psoriasis
  • Abnormal photosensitivity
  • Previous failure or intolerance to phototherapy


54 participants were included; 45 participants completed the study

Age: 27 to 52 years

Men: 30

Women: 14


InterventionsGroup 1

  • NB-UVB 3 times weekly. The initial dose was 70% of the MED. Incremental dose (at each visit) was 20% of the previous dose. The maximum dose was 2140 mJ/cm²


Group 2

  • PUVA twice weekly. The initial dose was 70% of the MPD. Incremental dose (at each visit) was 20% of the previous dose. Oral 8-methoxypsoralen at a dose of 0.6 mg/kg were taken 2 hours before UVA exposure. For those who could not tolerate 8-methoxypsoralen, 5-methoxypsoralen at a dose of 1.2 mg/kg was prescribed


The end point of the study was complete clearance of psoriasis


Outcomes
  1. The number of treatments for clearance
  2. Time for clearance
  3. Time for remission
  4. Adverse events


NotesSome outcomes (e.g. grade 2 erythema, pruritus, subgroup analyses according to PASI score, etc) were not fully reported with statistical data. In addition, the trial included only participants with skin type I to III


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskAlthough participants were "randomly allocated to either treatment group", the method of randomisation was not clearly described

Allocation concealment (selection bias)Unclear riskInsufficient information was available

Blinding of participants and personnel (performance bias)
All outcomes
High riskThe authors stated that it was an "open trial"

Blinding of outcome assessment (detection bias)
All outcomes
High riskOnly 1 outcome (namely "remission") was assessed by "a blinded observer"

Incomplete outcome data (attrition bias)
All outcomes
Low riskAlthough 9 (17%) participants discontinued the study, the reason for discontinuation was clearly reported, and the withdrawals were distributed equally between both groups

Selective reporting (reporting bias)High riskSome outcomes (e.g. grade 2 erythema, pruritus, subgroup analyses according to PASI score, etc) were not supported by statistical data

Other biasUnclear riskInsufficient information was available

Salem 2010

MethodsThis was a randomised controlled trial conducted in Egypt


ParticipantsInclusion criteria of the trial

  • People with psoriasis who were suitable for phototherapy


Exclusion criteria of the trial

  • Any topical or systemic treatment for at least 1 month
  • People suffering from hepatitis, diabetes, asthma, anaemia, or any chronic infection


36 participants were included for randomisation, and 34 of them completed the study

Age: 13 to 63 years

Men: 18

Women: 16


InterventionsGroup 1

  • Bath PUVA 3 times weekly up to a maximum of 24 sessions or until their psoriasis cleared. Before the UVA irradiation, 250 mg of methoxsalen was dissolved in 100 L of bath water giving a concentration of 2.5 mg/l, and then the participants soaked in the water for 20 minutes. Following the soak, participants were immediately exposed to the UVA. Fitzpatrick's skin types I to II received an initial dose of 0.5 J/cm²; skin type III received 0.75 J/cm²; skin type IV received 1 J/cm²; and skin type V received 1.25 J/cm². There was a routine increase in the UVA dose of 0.25 to 0.5 J/cm² per visit depending on the skin phototype and the degree of erythema


Group 2

  • NB-UVB 3 times weekly up to a maximum of 24 sessions or until their psoriasis cleared. The initial dose was determined according to the participant's skin type: skin types I and II received 0.3 J/cm²; skin types III and IV received 0.5 J/cm²; and skin types V and VI received 0.8 J/cm². Dose increments of 20% were applied every session if there was no erythema; 10% if there was minimal erythema; while no increments were applied in the presence of intense erythema, edema, blister, or any of the aforementioned


Adjunctive therapy was restricted to emollients


Outcomes
  1. PASI score reduction
  2. Clearence rate
  3. Number of treatments
  4. Cumulative UV dose
  5. Peripheral CD4+ T cell (%)
  6. Peripheral CD8+ T cell (%)
  7. CD4+/CD8+ ratio
  8. Adverse events


NotesPASI evaluation was of the lesions in the trunk and upper and lower extremities. In other words, facial or scalp psoriasis was not taken into account. In addition, PASI score was higher in the bath PUVA group than in the NB-UVB group. Also, the trial included participants with skin type I to V


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "...simple randomisation"

Comment: There was no further information

Allocation concealment (selection bias)Unclear riskInsufficient information was available

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information was available

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Assessment of the disease severity before and after treatment was carried out by two dermatologists in an observer-blinded fashion"

Incomplete outcome data (attrition bias)
All outcomes
Low riskOnly 2 (6%) participants withdrew from the study after randomisation. The reasons for withdrawal were reported and had no relation to the study

Selective reporting (reporting bias)Low riskAll outcomes described in the methods section were reported in the results of the trial report. In addition, the mean, 95% CI, and P value were all reported for the main outcomes

Other biasUnclear riskInsufficient information was available

Sezer 2007

MethodsThis was a randomised, controlled, within-patient, side-to-side comparison trial conducted in Turkey


ParticipantsInclusion criteria of the trial

  • People with biopsy-proven palmoplantar psoriasis (PPP) of more than 6 months duration in which conventional therapies other than phototherapy proved ineffective


Exclusion criteria of the trial

  • Topical treatment with corticosteroids within 2 weeks or systemic treatment with systemic immunosuppressive agents and retinoids within the last 4 weeks
  • Unilateral disease
  • Pregnancy
  • The inability to meet for follow-up consultations


25 participants were included; 21 of them completed the study

Age: 19 to 75 years

Men: 14

Women: 11


InterventionsThe NB-UVB and PUVA treatments were assigned randomly to the left or right hand, foot, or both. The treatments in both groups were used 3 times weekly over 9 weeks

Group 1

  • NB-UVB was administered 3 times weekly with an initial dose of 0.15 J/cm². An increasing percentile dose schedule based on an increase of 20% was used in every session, until a final dose of 2 J/cm² was reached


Group 2

  • UVA was administered 3 times weekly with an initial dose of 1.0 J/cm², with an increase of 0.5 J/cm² every second session until a final dose of 7.5 J/cm² was achieved. The hand, foot, or both, was painted with 1% 8-methoxypsoralen in a hydrophilic water/oil emulsion 15 minutes before the UVA exposure


Only topical emollients were allowed between treatment sessions in both groups


Outcomes
  1. Severity Index (SI) scores of PPP
  2. Clearance rate
  3. Marked improvement rate
  4. Severity of relapse
  5. Adverse events


NotesThe unit of analysis was the half-body. Additionally, the trial did not report the participants' skin type


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomisation was performed using a computer-based programme

Allocation concealment (selection bias)Unclear riskInsufficient information was available

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information was available

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Clinical assessments were performed by a blinded investigator"

Incomplete outcome data (attrition bias)
All outcomes
Low risk4 (16%) participants dropped out. The reasons for dropouts were reported and unrelated to the study

Selective reporting (reporting bias)High riskSome outcomes (e.g. cumulative doses) were not fully reported. Standard deviation and P value were omitted

Other biasHigh riskThe unit of analysis was the half-body. Withdrawal of 1 body-half for any reason inevitably caused withdrawal of the other half. In addition, each participant received both treatment regimens; the treatment to 1 side might have affected the other. All of these pitfalls might have induced other bias

Snellman 2004

MethodsThis was a randomised, controlled, single-blind, within-patient, side-to-side comparison trial conducted in Finland from September 2001 to March 2002


ParticipantsInclusion criteria of the trial

  • People with chronic plaque psoriasis who were suitable for and in need of phototherapy
  • Skin type should be II to IV
  • Wash-out period was 2 months for all systemic psoriasis treatments or phototherapy, and 2 weeks for topical antipsoriasis treatments


Exclusion criteria of the trial

  • Not clearly reported


18 participants were enrolled; 17 of them completed the study

Age: 46 ± 12 years

Men: 13

Women: 4


InterventionsHalf-bodies (left or right) of the included participants were randomly assigned to receive NB-UVB or bath PUVA. A maximum of 30 treatments of each type of irradiation were given. After disappearance of psoriasis on either treatment side, that treatment was withdrawn, but the other was continued

Group 1

  • NB-UVB 3 times weekly. NB-UVB was given first to avoid interaction with TMP. The initial dose was 50% of the MED, then it was incrementally increased each time by 20% to 30% until erythema appeared or a dose of 1 J/cm² was reached. Thereafter, the dose was increased by 10% to 20%. If erythema developed, the dose was kept constant, reduced, or not given


Group 2

  • PUVA 3 times weekly. A standard commercial alcohol solution of trioxysalen 50 mg/100 ml was diluted in 150 l of tap water to produce a standard 0.33 mg/l bath concentration. The bathing time was 10 minutes. For skin phototype II, the initial dose was 0.05 J/cm², and each dose was applied at least 3 times. Increments were initially 20% to 30%, and thereafter, 10%. For skin phototypes III and IV, the initial dose was slightly higher, 0.07 J/cm², and each dose was used at least twice


Adjunctive therapy was restricted to emollients and salicylic acid in white petrolatum


Outcomes
  1. PASI score reduction
  2. Global Improvement Score (GIS) reduction
  3. Target Lesion Score (TLS) reduction
  4. Time to clearance
  5. Clearance rate
  6. Adverse events


NotesThe unit of analysis was the half-body. In addition, the trial included participants with skin type II to IV


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe randomisation was on the basis of "an automatically computed random number table"

Allocation concealment (selection bias)Low risk"Sealed envelopes" were used

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information was available

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe investigator was masked

Incomplete outcome data (attrition bias)
All outcomes
Low risk3 (18%) participants discontinued the study; 1 of them withdrew before any interventions or assessments were performed because of his busy schedule and was not analysed. The other 2 withdrew due to personal reasons and deterioration on the PUVA side, respectively. The latter 2 participants were included in the analysis

Selective reporting (reporting bias)Low riskAll outcomes described in the methods section were reported appropriately in the results of the trial report

Other biasHigh riskThe unit of analysis was the half-body. Withdrawal of 1 body-half for any reason inevitably caused withdrawal of the other half. In addition, each participant received both treatment regimens; the treatment to 1 side might have affected the other. All of these pitfalls might have induced other bias

Storbeck 1993

MethodsThis was a randomised, controlled, within-patient, side-to-side comparison trial conducted in Germany from October 1989 to May 1990


ParticipantsInclusion criteria of the trial

  • People with Fitzpatrick skin type I to IV who had widespread symmetric psoriasis, including plaque type, guttate type, and erythroderma type


Exclusion criteria of the trial

  • Not reported


23 participants were included and completed the study

Age: 17 to 66 years

Gender: not reported


InterventionsGroup 1

  • NB-UVB and dithranol


Group 2

  • Selective BB-UVB and dithranol


Group 3

  • NB-UVB


Group 4

  • Selective BB-UVB


Irradiation was performed 3 to 5 times weekly. The initial dose of both irradiation doses was 70% of the MED. Dose increments of 10% were applied every session if there was no erythema, 5% if there was slight erythema, while no increments were applied in the presence of moderate erythema. Dose decrements of 10% were applied every session if there was marked erythema. Irradiation was suspended if there was burning


Outcomes
  1. PASI score reduction
  2. Cumulative irradiation dose


NotesThe unit of analysis was the half-body. The trial included participants with skin type I to IV


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe method of randomisation was not reported

Allocation concealment (selection bias)Unclear riskNo related information was available

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskThe authors did not mention whether the blinding method was used or not

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThe authors did not mention whether the blinding method was used or not

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll included participants completed the study and were analysed and reported as well

Selective reporting (reporting bias)High riskSome outcomes were not supported by statistical data. For example, In 11 of 13 patients the Philips TL 01/100 W lamp proved to be more effective than the Sylvania lamp"

Other biasHigh riskThe unit of analysis was the half-body. Each participant received both treatment regimens; the treatment on 1 side might have affected the other, which might have induced other bias

Yones 2006

MethodsThis was a randomised, placebo-controlled, double-blind trial conducted in the UK from April 2002 to March 2005


ParticipantsInclusion criteria of the trial

  • People with moderate-to-severe chronic plaque psoriasis


Exclusion criteria of the trial

  • Younger than 18 years or older than 70 years
  • Previous skin malignancy
  • Photo(chemo)therapy in the preceding 3 months or more than 150 sessions in the participant's lifetime
  • Administration of a drug known to frequently cause photosensitisation
  • Topical antipsoriatic treatment in the previous 4 weeks or systemic antipsoriatic treatment in the previous 3 months
  • Pregnancy, lactation, renal, or hepatic disease
  • A history of photosensitivity


93 participants were included; 88 of them completed the study

Men: 64

Women: 9


InterventionsParticipants were randomly assigned to receive NB-UVB and PUVA therapy

Group 1

  • NB-UVB twice weekly combined with placebo tablets. The initial irradiation dose was 70% of the MED. 20% incremental increases were used at each visit, if tolerated. The maximum dose was 5 J/cm². Doses were adjusted according to the occurrence of any erythema after treatments


Group 2

  • PUVA twice weekly combined with 8-methoxypsoralen (25 mg/m² BSA). If participants did not tolerate 8-methoxypsoralen due to nausea, 5-methoxypsoralen (50 mg/m² BSA) was the alternative choice. The initial irradiation dose was 70% of the MPD. 20% incremental increases were used at each visit, if tolerated. The maximum dose was 15 J/cm². Doses were adjusted according to the occurrence of any erythema after treatments


Adjunctive therapy was restricted to emollients and aqueous cream.

Treatment was terminated in the event of any of the following: clearance of psoriasis, absent or minimal improvement after 16 treatments or very slow progress thereafter, intolerance to therapy, or the completion of 30 treatments


Outcomes
  1. PASI score
  2. Physician's Global Evaluation score
  3. Dermatology Life Quality Index score
  4. Visual analogy scale
  5. Replase rate
  6. Adverse events


NotesThe trial included participants with skin type I to VI


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"A sequentially numbered list" was used

Allocation concealment (selection bias)Unclear riskInsufficient information was available

Blinding of participants and personnel (performance bias)
All outcomes
Low riskParticipants were blinded. It was not clear whether personnel were blinded

Blinding of outcome assessment (detection bias)
All outcomes
Low riskObservers were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskOnly 5 (5%) participants discontinued the study. The withdrawals were distributed equally between both groups

Selective reporting (reporting bias)Low riskAll outcomes described in the methods section were reported appropriately in the results of the trial report

Other biasUnclear riskInsufficient information was available

Özdemir 2008

MethodsThis was a randomised, controlled, single-blind, parallel trial conducted in Turkey from August 2005 to Decemeber 2006


ParticipantsInclusion criteria of the trial

  • People with Fitzpatrick's skin type II to V who were diagnosed with moderate to severe plaque psoriasis (more than 20% of their total BSA and a minimum PASI of 10)
  • People should also have stopped all topical therapy at least 4 weeks before the study and all systemic therapies for at least 6 months before the study


Exclusion criteria of the trial

  • Pregnant women
  • Age < 18 years
  • A history of skin cancer or solar keratoses
  • A history of phototherapy
  • Localised palmoplantar psoriasis
  • Pregnancy, lactation, renal, or liver diseases
  • Hyperlipoproteinemias
  • Severe cardiac and neurological diseases
  • People receiving other systemic therapy for psoriasis, such as acitretin or methotrexate
  • Those who had received any form of UV therapy within the preceding 6 months
  • People with guttate, erythrodermic, or pustular psoriasis


60 participants were included; 52 of them completed the study

Age: 37.2 ± 11.6 years in the NB-UVB group; 36.1 ± 9.9 years in the PUVA group

Men: 34

Women: 26


InterventionsDuring the first week, participants in both groups received acitretin (0.3 to 0.5 mg/kg per day). NB-UVB or PUVA were then started in the second week in the different groups, respectively

Group 1

  • Combined with acitretin, NB-UVB was used 3 times weekly. The initial dose was 70% of the MED, which subsequently increased by 10% to 20% increments at each visit


Group 2

  • Combined with acitretin, PUVA was used 3 time weekly. Additionally, 2 hours before irradiation (0.6 mg/kg) 8-methoxypsoralen was administered. The initial dose of PUVA was 70% of the MPD, with 20% increments weekly


During the study and the follow-up period, additional therapy was restricted to the use of emollients that were applied once daily in the evening

Treatments were discontinued when neither improvement nor exacerbation was seen after 6 weeks, or when severe side-effects occurred or laboratory analyses showed abnormalities


Outcomes
  1. The mean reduction in PASI score before and after treatment
  2. The number of participants who reached PASI 75, marked improvement, moderate improvement, slight improvement, unchanged, and exacerbation in PASI, respectively
  3. Overall tolerability of treatment (assessed by clinicians)
  4. Overall tolerability of treatment (assessed by participants)
  5. Adverse events


NotesThe trial included participants with skin type II to V


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Randomised assignment of the two treatments was performed by asking the patients to throw a dice without knowing the underlying allocation criteria"

Allocation concealment (selection bias)Unclear riskInsufficient information was available

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskInsufficient information was available

Blinding of outcome assessment (detection bias)
All outcomes
Low riskObservers were masked

Incomplete outcome data (attrition bias)
All outcomes
Low risk8 (13%) participants discontinued the study. The reasons for discontinuation were clearly reported, and the withdrawals were distributed equally between both groups. ITT analyses were performed for the main outcomes

Selective reporting (reporting bias)Unclear riskAll outcomes described in the methods section were reported in the results of the trial report

Other biasUnclear riskInsufficient information was available

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Boer 1984This was a non-randomised controlled trial

Coven 1997This was a non-randomised controlled trial

Dayal 2010This was not a real randomised controlled trial. Participants who were recruited on Monday, Wednesday, or Friday received NB-UVB, whereas those who were recruited on Tuesday, Thursday, or Saturday received PUVA

Malhotra 2010This was an abstract of a conference paper (not a RCT)

Roson 2005This was a quasi-randomised trial

Tanew 1996This was an abstract of a conference paper; it was a non-randomised controlled trial

Ul 2005The authors compared PUVA with UVB in this trial. They did not clearly define the type of UVB they used. Was it NB-UVB, BB-UVB, or both of them? We could not draw a conclusion from the paper. And we failed to make contact with the corresponding author to get more information

 
Characteristics of studies awaiting assessment [ordered by study ID]
Nazari 2005

MethodsThis was a randomised controlled trial conducted in Turkey

Participants32 participants with chronic plaque psoriasis were included

Interventions
  • Group 1: NB-UVB 3 times weekly
  • Group 2: PUVA 3 time weekly

Outcomes
  1. Clearance of psoriasis
  2. Remission rate within 6 months after treatment completion

NotesThe study was published in Turkish, and we are awaiting a translation

 
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

 
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

NB-UVB compared with bath PUVA for chronic plaque psoriasis

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

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

Assumed riskCorresponding risk

Bath 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 75Study populationNot estimable0
(0)
See commentNo included RCT addressed this outcome

See commentSee comment

Moderate


Withdrawal due to side-effectsStudy populationNot estimable0
(0)
See commentNo included RCT addressed this outcome

See commentSee comment

Moderate


Clearance rate348 per 1000623 per 1000
(160 to 1000)
RR 1.79
(0.46 to 6.91)
92
(2 studies)
⊕⊕⊝⊝
low¹
1. On the basis of studies performing left-right body comparison. 2. This is the result of ITT analysis

Clearance rate611 per 1000110 per 1000
(31 to 434)
RR 0.18
(0.05 to 0.71)
36
(1 study)
⊕⊕⊝⊝
low², ³
1. On the basis of the study performing comparison between participants. 2. This is the result of ITT analysis

*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 Both of the studies were of small sample size and at high risk of bias, and the result was based on less than 300 participants.
² The study was at high risk of bias.
³ The study was of small sample size, and the result was based on less than 300 participants.
 
Summary of findings 3. NB-UVB compared with topical PUVA for palmoplantar psoriasis

NB-UVB compared with topical PUVA for palmoplantar psoriasis

Patient or population: People with palmoplantar psoriasis
Settings: -
Intervention: NB-UVB
Comparison: Topical PUVA

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

Assumed riskCorresponding risk

Topical 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 75Study populationNot estimable0
(0)
See commentNo included RCT addressed this outcome

See commentSee comment

Moderate


Withdrawal due to side-effectsStudy populationNot estimable0
(0)
See commentNo included RCT addressed this outcome

See commentSee comment

Moderate


Clearance rate200 per 100018 per 1000
(2 to 312)
RR 0.09
(0.01 to 1.56)
50
(1 study)
⊕⊕⊝⊝
low¹, ²
This is the result of ITT analysis

* Comment: The basis for the assumed risk (e.g. the median control group risk across studies) is provided in 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 This study was at unclear risk of bias.
² The study was of small sample size, and the result was based on less than 300 participants.
 
Summary of findings 4. NB-UVB plus retinoid compared with PUVA plus retinoid for chronic plaque or guttate psoriasis

NB-UVB plus retinoid compared with PUVA plus retinoid for chronic plaque or guttate psoriasis

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

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

Assumed riskCorresponding risk

PUVA plus retinoidNB-UVB plus retinoid

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

See commentSee comment

Moderate


Percentage of participants reaching PASI 75Study populationRR 0.89
(0.59 to 1.35)
60
(1 study)
⊕⊕⊝⊝
low¹, ²
This is the result of ITT analysis

633 per 1000564 per 1000
(374 to 855)

Moderate


Withdrawal due to side-effectsStudy populationNot estimable0
(0)
See commentNo included RCT addressed this outcome

See commentSee comment

Moderate


Clearance rate756 per 1000688 per 1000
(544 to 831)
RR 0.93
(0.79 to 1.10)
90
(2 studies)
⊕⊕⊝⊝
low², ³
This is the result of ITT analysis

*Comment: The basis for the assumed risk (e.g. the median control group risk across studies) is provided in 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 This study was at high risk of bias.
² The studies were of small sample size, and the result was based on less than 300 people.
³ Both of the studies were at high risk of bias.
 
Summary of findings 5. NB-UVB compared with selective BB-UVB for chronic plaque psoriasis

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

Patient or population: People with chronic plaque psoriasis
Settings: -
Intervention: NB-UVB
Comparison: Selective BB-UVB

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

Assumed riskCorresponding risk

Selective BB-UVBNB-UVB

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

See commentSee comment

Moderate


Percentage of participants reaching PASI 75Study populationNot estimable0
(0)
See commentNo included RCT addressed this outcome

See commentSee comment

Moderate


Withdrawal due to side-effectsStudy populationRR 3.00
(0.32 to 27.87)
100
(1 study)
⊕⊕⊝⊝
low¹, ²
This is the result of ITT analysis

20 per 100060 per 1000
(6 to 557)

Moderate


Clearance rate400 per 1000560 per 1000
(368 to 852)
RR 1.40
(0.92 to 2.13)
100
(1 study)
⊕⊕⊝⊝
low¹, ²
This is the result of ITT analysis

*Comment: The basis for the assumed risk (e.g. the median control group risk across studies) is provided in 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 at unclear risk of bias.
² The study was of small sample size, and the result was based on less than 300 people.
 
Table 1. Glossary of some important terms and abbreviations used

Medical term and abbreviationsExplanation

ApoptosisThe process of programmed cell death that occurs during growth and development of multicellular organisms. It is generally considered a part of normal cell aging, but it can also be a response to cellular injury

BB-UVBBroad-band ultraviolet B

CollagenaseAn enzyme that breaks the peptide bonds in collagen

CPPChronic plaque psoriasis

CytokinesSmall protein molecules that are secreted by cells of the nervous system or the immune system. They are used in intercellular communication

Defective maturation of epidermal keratinocytesIncomplete formation of keratin (the horny material in nails) due to rapid growth of cells in the epidermal layer of the skin

Dilatation of dermal capillariesDilation of small blood vessels in the skin

Erythrodermic psoriasisA subtype of psoriasis that affects nearly all body sites

Erythrogenic responseRedness of the skin caused by light exposure

Extensor aspectsAn anatomical term - when a joint bends, the parts of the skin on the opposite side of the joint are called the extensor aspects

HyperkeratosisThickening of the stratum corneum (outermost layer of the skin) usually associated with an abnormality of the keratin and an increase of the granular layer of the skin

HyperplasiaAn increase in the number of cells

HyperproliferationAn abnormally high rate of proliferation of cells by rapid division

HypertriglyceridaemiaHigh levels of triglyceride fatty acids

ITTIntention-to-treat: An ITT analysis is often recommended as the least biased way to estimate intervention effects in RCTs. The principals of ITT analysis are as follows: 1. keep participants in the intervention group to which they were randomised, regardless of the intervention they actually received; 2. measure outcome data on all participants; and 3. include all randomised participants in the analysis

MRAMinimal residual activity

MOPMethoxypsoralen

NB-UVBNarrow-band ultraviolet B

ParonychiaSwelling of the skin over the nail

PASIPsoriasis Area and Severity Index. The higher the score, the more severe the lesions are

PASI 75Equal to or more than 75% reduction in PASI score

PPPPalmoplantar psoriasis

PsoralenA compound that can be used as a kind of photosensitiser to improve the influence of natural or artificial light

PUVAPsoralen plus ultraviolet A

PhotosensitiserChemical treatments that are used to sensitise the skin and enhance the effect of light treatments

PustularLesions containing purulent materials

QOLQuality of life

Re-NB-UVBNB-UVB combined with retinoid

Re-PUVAPUVA combined with retinoid

Severity index of PPPA tool developed by Hofer 2006 to evaluate the severity of palmoplantar psoriasis. The separate scores of erythema, scaling, pustulation, and infiltration for palms and soles were added to calculate the severity index (0 = absent; 1 = slight; 2 = moderate; 3 = marked; and 4 = very marked)

XerophthalmiaDryness of the eye, especially the cornea and conjunctiva

XerosisExtreme dryness of the skin