1. PUVA
   

   Aetna considers psoralens and ultraviolet A light (PUVA) treatments medically necessary for the following conditions after conventional therapies have failed:

   • Alopecia areata;
   • Chronic palmoplantar pustulosis;
   • Cutaneous T-cell lymphoma (mycosis fungoides);
   • Cutaneous manifestations of graft versus host disease;
   • Eosinophilic folliculitis and other pruritic eruptions of HIV infection;
   • Granuloma annulare;
   • Morphea (circumscribed scleroderma) and localized skin lesions associated with scleroderma;
   • Necrobiosis lipoidica;
   • Photodermatoses;
   • Pityriasis lichenoides;
   • Severe lichen planus;
   • Severe parapsoriasis;
   • Severe refractory atopic dermatitis/eczema;
   • Severe refractory pruritus of polycythemia vera;
   • Severe urticaria pigmentosa (cutaneous mastocytosis);
   • Severely disabling psoriasis (i.e., psoriasis involving 10 % or more of the body, or severe psoriasis involving the hands, feet, or scalp);
   • Vitiligo.

   Generally 2 to 3 PUVA treatments per week for up to 23 weeks are considered medically necessary for psoriasis.  After 23 weeks, the medically necessary frequency of PUVA therapy is 1 treatment every 1 to 3 weeks with the majority of persons treated once every 3 weeks for an indefinite period.  If the psoriasis fails to improve after 2 months of PUVA therapy, continued treatment is generally not considered medically necessary due to lack of efficacy.  Note: Home PUVA treatment is considered experimental and investigational because of insufficient evidence of its safety and effectiveness.

   Aetna considers PUVA treatment experimental and investigational for all other indications.  There is inadequate evidence in the peer-reviewed medical literature of the effectiveness of PUVA in any of these conditions (not an all-inclusive list):

   • Acne;
   • Keratosis follicularis (Darier disease or Darier-White disease);
   • Lichen amyloidosis;
   • Lichen myxedematosus;
   • Melasma;
   • To increase skin tolerance to sunlight.

2. UVA/UVB

   Aetna considers phototherapy with UVA medically necessary for the following indications:

   • Acne;
   • Eczema;
   • Eosinophilic folliculitis and other pruritic eruptions of HIV infection;
   • Lichen planus;
   • Morphea (circumscribed scleroderma);
   • Parapsoriasis;
   • Photodermatoses;
   • Pityriasis lichenoides;
   • Pityriasis rosea;
   • Prurigo nodularis;
   • Psoriasis.

   Aetna considers the use of UVA experimental and investigational for infectious keratitis, lymphomatoid papulosis and all other indications because there is inadequate evidence in the peer-reviewed medical literature of the effectiveness of UVA in any of these conditions . 

   Aetna considers UVB with the addition of topical coal tar (also known as the Goeckerman regimen) or petrolatum medically necessary for persons with severe psoriasis (defined as psoriasis that affects more than 10 % of body surface area).  Aetna considers UVB with the addition of topical coal tar or petrolatum experimental and investigational for all other indications (e.g., pemphigoid, pruritis).

   Aetna considers home phototherapy (UVB) treatment medically necessary DME for persons with severe psoriasis with a history of frequent flares who are unable to attend on-site therapy or those needing to initiate therapy immediately to suppress psoriasis flares.  Home ultraviolet light booths or ultraviolet lamps, as well as replacement bulbs sold by prescription only, are considered medically necessary for persons eligible for home UVB phototherapy.

   Aetna considers narrow-band UVB phototherapy medically necessary for psoriasis, atopic dermatitis (atopic eczema) and early-stage mycosis fungoides.  For narrow-band UVB phototherapy for vitiligo, see CPB 0422 - Vitiligo.

   Aetna considers narrow-band UVB phototherapy experimental and investigational for all other indications (e.g., acquired perforating dermatitis, chemical dermatitis/contact dermatitis, cholestasis of pregnancy, dermatographic urticaria (also known as dermographism and dermatographism), graft-versus-host disease, granuloma annulare, hidradenitis suppurativa, lichen simplex chronicus, morphea, papular urticaria, progressive macular hypomelanosis, pruritus, scleroderma, skin hypo-pigmentation from scarring, and superficial mixed-cell dermatitis; not an all inclusive list) because there is inadequate evidence in the peer-reviewed medical literature of the effectiveness of narrow-band UVB in any of these conditions . 

   For excimer laser treatment of psoriasis, see CPB 0577 - Laser Treatment for Psoriasis and Other Selected Skin Conditions.

   Aetna considers tanning beds for home UVB phototherapy not medically necessary.  Unlike tanning beds, home UVB devices are designed solely for the medical treatment of skin diseases and emit a different wavelength of ultraviolet light than tanning beds.  Note: In addition, tanning beds do not meet Aetna's definition of covered durable medical equipment in that they are of use in the absence of illness or injury. 

   See also CPB 0656 - Phototherapy for Acne. 

Psoralens and ultraviolet A light (PUVA) therapy is contraindicated in any of the following conditions:

• History of arsenic exposure; or
• History of ionizing radiation exposure; or
• History or presence of melanoma or other skin cancer; or
• Pregnancy.

The National Institute for Health and Clinical Excellence's procedure guidance on "Photochemical corneal collagen cross-linkage using riboflavin and ultraviolet A for keratoconus" (NICE, 2009) concluded that "[c]urrent evidence on the safety and efficacy of photochemical corneal collagen cross-linkage using riboflavin and ultraviolet A (UVA) for keratoconus is inadequate in quantity and quality.  Therefore this procedure should only be used with special arrangements for clinical governance, consent and audit or research".

Khan and colleagues (2011) presented the first 3 cases of Acanthamoeba keratitis (AK), unresponsive to medical treatment, that were successfully treated with a novel adjunctive therapy using UVA and riboflavin (B2).  Two patients with confirmed AK and 1 patient with presumptive AK, which were all refractive to multi-drug conventional therapy were included in this study.  Two treatment sessions involving topical application of 0.1 % B2 solution to the ocular surface combined with 30 mins of UVA irradiation focused on the corneal ulcer were carried out.  Main outcome measures were clinical examination by slit lamp, confocal microscopy, and histopathology, when available.  All patients in these series showed a rapid reduction in their symptoms and decreased ulcer size after the first treatment session.  The progress of the clinical improvement began to slow after 1 to 3 weeks of the first application and was then renewed after the second application.  All ancillary signs of inflammation mostly resolved after the second treatment session.  The ulcers in all patients continued to decrease and were closed within 3 to 7 weeks of the first application.  Two patients developed dense central corneal scars, and penetrating keratoplasty was performed for visual rehabilitation.  Histopathological examination of the excised tissue revealed no Acanthamoeba organisms.  The remaining patient had no symptoms or signs of infection, both clinically and by confocal microscopy, and was left with a semi-transparent eccentric scar that did not affect visual acuity.  The authors concluded that adjunctive use of UVA and B2 therapy seems to be a possible alternative for selected cases of medication-resistant AK.  Moreover, they noted that further research is needed and currently underway to examine how best to use photochemical therapy for the treatment of infectious keratitis.

Lowe (1992) stated that home UV phototherapy is extremely popular with many psoriasis patients.  However, it is essential that they understand the need for regular skin examination by the dermatologist.  Patients with psoriasis are not trained nor are many non-dermatologist physicians to recognize the early features of many skin cancers, and continued home UV therapy in the presence of such skin cancers is clearly unwise for the safety of that patient.  The use of UVA tanning salon treatments in the therapy of psoriasis is usually unsuccessful and is extremely unwise with concomitant psoralen and drug therapy.  This is to be discouraged, and the patient should always be treated with PUVA in the dermatologist's office with carefully monitored UVA machines and staff trained in the administration of PUVA phototherapy.

In an open-label, randomized controlled trial, van Coevorden et al (2004) examined if oral PUVA with a portable tanning unit at home is as effective as hospital-administered bath PUVA in patients with chronic hand eczema.  A total of 158 patients with moderate-to-severe chronic hand eczema (more than 1 year in duration) were included in this study.  The primary outcome was clinical assessment by a hand eczema score (evaluation of desquamation, erythema, vesiculation, infiltration, fissures, itch, and pain, each on a 4-point scale) after 10 weeks of treatment.  The secondary outcome was hand eczema score at 8 weeks of follow-up, after completion of treatment.  The tertiary outcome was travel cost and time off work.  Both groups showed a comparable and substantial decrease in hand eczema score (meaningful clinical improvement).  This decrease was maintained during the follow-up period.  Patients treated with oral PUVA at home had lower travel costs and less time off work.  The authors concluded that oral PUVA at home has a clinically relevant efficacy, similar to that of hospital-administered bath PUVA.  This effect was maintained during an 8-week follow-up period.  It resulted in lower travel costs and less time off work.  These promising results need to be validated by more research.

Dermatographic urticaria (also known as dermographism and dermatographism) is a skin disorder observed in 4 to 5 % of the population and is one of the most common types of urticaria, in which the skin becomes raised and inflamed when stroked, scratched, rubbed, and sometimes even slapped.  Dermatographic urticaria can be treated by anti-histamines, which may need to be given as a combination of H1 antagonists, or possibly with an H2-receptor antagonist such as cimetidine.  Therapies may also include immunosuppressive agents and steroids.  There is a lack of evidence regarding the clinical value of narrow-band UVB phototherapy in the treatment of this condition.

Kreutz et al (2012) noted that depletion of host Langerhans cells (LCs) prevents cutaneous graft-versus-host disease (GVHD) in mice.  These researchers analyzed whether UVB irradiation is tolerated during the course of human allogeneic hematopoietic cell transplantation and whether depletion of LCs by broadband UVB could improve GvHD outcome.  A total of 17 patients received 6 whole-body UVB irradiations with 75 % of the individually determined minimal erythemal dose after conditioning with a reduced intensity protocol.  Langerhans cells, dermal dendritic cells (DCs), and macrophages were analyzed before and after UVB irradiation by immunohistochemical analysis.  Circulating blood cells and serum factors were analyzed in parallel.  In striking contrast to previous data, this irradiation protocol was well-tolerated in all patients.  Treatment with UVB decreased the number of LCs and also affected dermal DCs.  Patients treated with UVB also had significantly higher 25-hydroxyvitamin D3 serum levels and higher numbers of circulating CD4+ FoxP3+ regulatory T cells.  Strikingly, 9 out of 9 patients with complete LC depletion (less than 1 LC per field) developed only grade I GVHD or no GVHD up to day 100.  The authors concluded that these results strongly suggest that prophylactic UVB irradiation post-transplant is safe and should be further explored as a clinical strategy to prevent acute (skin) GVHD.

Duarte et al (2010) noted that progressive macular hypomelanosis (PMH) is a common dermatosis; its cause is unknown and proposed treatments have had little effect.  These researchers examined epidemiological aspects of PMH in patients referred to a phototherapy clinic between 1997 and 2008 and evaluated therapeutic response to PUVA (psoralen + UVA) photochemotherapy or NB-UVB phototherapy.  A total of 84 patients with PMH were evaluated.  After 16 phototherapy sessions, therapeutic response was classified as: unchanged, slightly improved (less than 50 % of re-pigmentation), moderately improved (50 to 79 % of re-pigmentation), much improved (80 to 99 %) or cured (100 %).  After a minimum of 3 months, patients whose response was classified as cured or much improved were contacted by telephone to evaluate the persistence of the therapeutic response.  Most of the patients were women (79 %) and white (85 %).  Age at onset of PMH ranged from 13 to 36 years.  PUVA was prescribed for 27 patients and NB-UVB phototherapy for 57.  No significant difference was found between the outcomes obtained with PUVA and those obtained with NB-UVB phototherapy (Fisher's exact test; p < 0.05).  The majority of patients (81 %) had 50 % or more re-pigmentation, with 65 % being classified as cured or much improved.  Nevertheless, there was a recurrence of the lesions in 72 % of patients.  The authors concluded that the fact that no patients were over 40 years of age suggested that PMH is a self-limiting disease.  Both PUVA and NB-UVB are effective therapeutic options; however, they do not prevent recurrence of the disease.  The main drawback of this study was its uncontrolled nature and small sample size.

Montero et al (2011) stated that PMH is an acquired disorder of skin pigmentation, which is mostly under-diagnosed.  It is characterized by nummular hypo-pigmented lesions appearing on the trunk in young persons.  Several treatment options are available, although topical clindamycin and benzoyl peroxide have been used traditionally.  However, good results have recently been achieved using NB-UVB phototherapy.  These researchers presented the case of a 13-year old girl with hypo-pigmented lesions on the trunk and limbs that had progressed over 1 year and that were diagnosed as PMH.  The patient was initially treated with topical clindamycin and benzoyl peroxide.  However, little improvement was seen and treatment was then started with NB-UVB phototherapy.  After 25 sessions, with a total cumulative dose of 18 J/cm(2), the patient showed almost total re-pigmentation of the lesions.  The treatment of PMH is often difficult, and very little is currently known about the treatment response in this disorder, as most reports have very small series of patients with a short disease progression time.  The authors concluded that NB-UVB phototherapy has been shown to be effective, as seen in this patient, although in many cases, there is recurrence after the cessation of treatment.

Kim et al (2012) examined the clinical features of PMH in Koreans and determined the therapeutic efficacy of NB-UVB therapy in the management of PMH.  These investigators performed an uncontrolled prospective study designed to evaluate the usefulness of NB-UVB therapy in PMH.  A total of 23 patients with PMH were enrolled in the study.  Of these, 17 patients underwent treatment with NB-UVB therapy once- or twice-weekly and were eligible for analysis.  The remaining 6 patients were lost to follow-up before completion of the treatment.  Re-pigmentation was evaluated by 2 dermatologists using photographic documentation.  Narrow band-UVB therapy was used successfully in 9 of 16 patients (56.2 %), who showed more than 90 % re-pigmentation.  They found that 13 of 16 patients (81.3 %) experienced at least 50 % re-pigmentation.  The re-pigmented sites showed an excellent color match.  No signs of recurrence have been detected in 11 of these 16 patients (68.7 %) up to the present time (13.2 +/- 8.2 months of follow-up).  The authors concluded that the findings of this study suggested that NB-UVB therapy is an effective and safe method for use in the treatment of PMH.  Drawbacks of this study included a small number of subjects examined, and it was an uncontrolled and non-double-blind study.

Note: Regarding UVB in the treatment of prurigo nodularis, Ferrandiz et al (1997) reported that an excellent response was obtained after an average of 32 UVB courses.

Note: Delrosso et al (2008) reported that an aggressive bath PUVA treatment is not substantially more effective in clearing chronic plaque-type psoriasis than a milder therapeutic approach.