Transcript Phototherapy and Emollients - Yorkshire Phototherapy Network

Phototherapy and Emollients
The Evidence Base
D Turner
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Introduction
Over many years opinion on what moisturisers to use and when
during phototherapy has been a common question asked by both
patients and staff.
One concern was the reduction of ultraviolet transmission through
the skin that may occur in the presence of an emollient thus
inhibiting the therapeutic effect.
Over several years there have been studies looking at the photoprotective properties of the various types of emollient.
Following is the evidence base as it has developed.
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1979
Schleider N, Moskowitz R, Cort D, Horwitz N, Frost P, 1979, Effects of
Emollients on Ultraviolet Radiation Induced Erythema of the Skin, Archives
of Dermatology, vol 115 (1188-91)
An in vivo technique using MEDs of three normal white adults to test
reduction of erythema after application of a variety of oils, petrolatum and
vaseline.
3 and 5 MED’s of UV were irradiated on each test substance and the erythema
evaluated at 6 and 24 hours
Found Vaseline, petrolatum and hydrophilic ointment had mild screening
effects. Oils such as Alpha Keri bath oil, corn oil and mineral oils may be used
instead.
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1994
Hudson –Peacock MJ, Diffey BL, Farr PM, 1994, Photo-protective action of
emollients in ultraviolet therapy of psoriasis, British Journal of Dermatology,
vol/iss 130/3 (361-5)
An in vitro technique using a monochromator to test protection factors.
Measured reduction in UV through different application amounts and
different wavelengths.
Added correction factors for psoralen sensitised skin.
Provided a list of the available emollients at that time and the ratio of UV
reduction.
A protection factor ratio of >1.2 is a 17% reduction in UV transmission and
therefore likely to be of clinical significance.
Found water based emollients reduced transmission the least – some
increased it.
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1995
Lebwohl M, Martinez J, Weber P, DeLuca R, 1995, Effects of topical
preparations on the erythemogenicity of UVB: implications for psoriasis
phototherapy, Journal of the American Academy of Dermatology, vol/iss
32/3 (469-71)
Volunteers pre-treated with mineral oil, clear liquid emollient, 5% crude coal
tar, 6% salicylic acid ointment, emollient creams and petrolatum underwent
MED testing.
Tar and salicylic acid blocked UVB. Thick application of petrolatum and
emollient creams reduced transmission of UVB. Mineral oil and clear liquid
emollients had no significant effect.
Concluded mineral oil and clear liquid emollients could be used before
phototherapy
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1996
Gabard B, Treffel P, Bieli E, Schwab S, 1996, Emollients and
photo(chemo)therapy: a call for caution. Dermatology, vol/iss 192/3 (242-5)
In vitro technique similar to testing of sun protection factors (monochromator
based measurements of transmission).
Found light oils enhanced UV transmission. High application levels or tinted
emollients showed significant interference with transmission.
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2000
Hoffman K, Kaspar K, Gambichler T, Altmeyer P, 2000, Change in ultraviolet
(UV) transmission following application of vaseline to non irradiated and
UVB exposed split skin. British Journal of Dermatology, vol/iss 142/3 (532-8)
In vitro split skin samples used.
Two density of applications of vaseline investigated .
Found vaseline increased transmission though samples. UVA required a lower
density of application (2.5mgcm-2) to increase transmission than UVB
(17.5mgcm-2)
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2002
Behrens-Williams SC, Kraus D, Reuther T, Kercher MJ, 2002, Do we alter
ultraviolet sensitivity in vivo with stratum corneum rehydration? A pilot
study. British Journal of Dermatology, vol/iss 146/2 (280-4)
Randomised double blind in vivo study.
UVB MED and electrical capacitance (to measure skin hydration) was
performed on normal skin in 10 volunteers each using 5 different emollients
(unguentum emulsificans and dilutions with 30, 50, 70 and 90% aqua
purificans) and one control.
Found no significant effect on erythema response. No correlation between
stratum corneum hydration and erythema response.
Concluded emollients suitable to use prior to UVB treatment.
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2005
Penven K, Leroy D, Verneuil L, Faguer K, Dompmartin A, 2005, Evaluation of
vaseline oil applied prior to UVB TL01 phototherapy in the treatment of
psoriasis. Photodermatol Photoimmunol Photomed, vol 21 (138-41)
15 patients single blind in vivo study.
One to three symmetrical pairs of plaques used. One side treated with
vaseline oil.
Each plaque scored for scaling, infiltration and erythema. Scores taken initially
and every six treatments
From the 6th exposure to end of treatment oil treated plaques had
significantly lower scores. Total clearance was achieved with significantly
fewer exposures in the oil treated plaques.
No side effects were noticed with vaseline oil
Concluded vaseline oil is recommended for use prior to UVB treatment.
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2006
Fetil E, Akarsu S, Ilknur E, Gunes AT, 2006, Effects of some emollients on the
transmission of ultraviolet, Photodermatology, Photoimmunology &
Photomedicine, vol/iss 22/3 (134-40)
In vivo study looked at petrolatum, basis cream, glycerine and olive oil using
UVB MEDs on 32 volunteers.
MED increased with white petrolatum and basis cream.
No change in MED with glycerine and olive oil.
Glycerine and olive oil can be used prior to phototherapy.
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2006
Otman SG, Edwards C, Pearse AD, Gambles BJ, Anstey AV, 2006, Modulation
of ultraviolet (UV) transmission by emollients: relevance to narrowband
UVB phototherapy and psoralen plus UVA photochemotherapy, British
Journal of Dermatology, vol/iss 154/5 (963-8)
30 topical emollients (non bath) from BNF using in vitro technique the same as
for sunscreens (using a monochromator). Mean protection factor calculated
for NB UVB wavelength and UVA.
Survey of phototherapy units to find out practice.
Provided a list of protection factors similar to Diffey for both wavelengths.
Conclusion - careful selection of emollient can increase UV transmission. In
general creams reduced transmission the least whereas ointments reduced it
most
Large majority of centres did not routinely use emollients prior to
phototherapy although a third did.
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2008
Kumar V, Bansal A, Kamal A, Kapil J, 2008, Enhanced response of Childhood
Psoriasis to Narrow-Band UVB Phototherapy with Preirradiation Use of
Mineral Oil , Pediatric Dermatology, vol/iss 25/5 (559-64)
20 children in prospective randomised single blinded study.
Mineral oil applied to one half of body 5 minutes prior to irradiation.
PASI scoring for each half of body at weeks 3, 6, 9 and twelve.
Significantly greater improvement in PASI score on mineral oil pre-treated side
evident at week 3 onwards.
Cumulative dose to clearance was significantly lower with mineral oil treated
site
No averse effects were noticed with the mineral oil.
Concluded pre-treatment with mineral oil enhances the therapeutic effect of
NB UVB in children with widespread psoriasis
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2011
Pacifico A, Leone G, 2011, Evaluation of a skin protection cream for dry skin
in patients undergoing narrowband UVB phototherapy for psoriasis vulgaris,
Giornale Italiano di Dermatologia e Venereologia, vol/iss 146/3 (179-83)
54 patients with moderate psoriasis vulgaris
Cream containing glycerol, vaseline and liquid paraffin vs. ointment
containing vaseline.
Applied twice a day including prior to phototherapy
Greater improvement in outcome in patients treated with cream than vaseline
ointment. Assessed by both clinician and patient questionnaire.
Improved skin hydration in cream group (not clear how they assessed that).
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2011
Skellet A, Swift L, Tan E, Garioch J, 2011, A randomised, double-blind
negatively controlled pilot study to determine whether the use of emollients
or calcipotriol alters the sensitivity of the skin to ultraviolet radiation during
phototherapy with narrowband ultraviolet B, British Journal of Dermatology,
vol 164 (402-6)
20 healthy volunteers
MED on normal skin and sites pre treated with 50:50 white soft paraffin and
liquid paraffin, Diprobase, Epaderm and calcipotriol cream and ointment.
Pre treated sites were allowed 30 min for emollients to be absorbed prior to
MED
No significant difference in MED for any site.
Pre treatment of skin with some heavy emollients immediately prior to
irradiation are more likely to block transmission. But if they are applied at least
30 min prior to treatment the have no effect.
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2013
Asztalos ML, Heller MM, Lee ES, Koo J, 2013, The impacts of emollients on
phototherapy: a review, Journal of the American Academy of Dermatology,
vol/iss 68/5 (817-24)
Review of literature
Psoriasis plaque clearance improves with serous (thin liquid) based emollients
(e.g. vaseline oil, mineral oil and glycerol).
Clearance decreased with salicylic acid and viscous based emollients (e.g.
petrolatum).
Liquid emollients with refractive indexes close to that of normal skin increase
UV penetration i.e. a reduction in reflectance that exceeded the emollients
innate ability to absorb UV.
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Conclusion
So what does it all mean?
Application of an emollient prior to phototherapy if carefully selected
and not within 30 minutes of treatment will have at least no significant
detriment to clearance and likely to improve outcome.
Application of emollients improves tolerability of treatment.
In detail
Lists of specific BNF products and their UV reduction is listed in both
Diffey’s and Anstey’s work.
Any with a therapeutic protection factor (TPP) of less than 1.2 is suitable
These are listed for both UVB and PUVA in both studies
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Conclusion
In general
Creams, oils or thin liquid emollients improve or have no significant
effect on clearance.
Viscous emollients, and ointments require at least 30 min to be
absorbed after which they have no detrimental effect
Tars, tinted emollients (e.g. yellow soft paraffin) and salicylic acid block
or significantly reduce UV transmission.
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