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Aetna Aetna
Clinical Policy Bulletin:
Phototherapy and Photochemotherapy (PUVA) for Skin Conditions
Number: 0205


Policy

  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;
    • Polymorphous light eruption;
    • 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), early-stage mycosis fungoides, and polymorphous light eruption.  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



Background

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 narrow-band ultraviolet B (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.

Berg et al (1994) carried out a study in 22 patients with polymorphous light eruption (PMLE) who were prophylactically treated with UVA with and without trimethylpsoralen; 12 of the patients were treated during 2 consecutive springs with placebo during one spring and psoralens during the other.  Eighteen of the patients improved after the therapy, but there was no clear-cut difference between the 2 regimens.  As many as 12 patients got light eruptions during the treatment, but all but 1 continued with the therapy.  The authors concluded that the findings of this study indicated that UVA alone is as good prophylactic therapy for PMLE as PUVA with trimethylpsoralen.  However, because of the high incidence of provoked eruptions during therapy, the treatment may be difficult to handle for the patients themselves, at least during the initial treatment.

Fesq and colleagues (2003) stated that management of PLE should focus on basic preventative measures and additional therapeutic approaches, depending on the clinical condition.  Polymorphous light eruption can be classified into 4 severity groups: (i) mild, (ii) moderate-to-severe, (iii) severe, and (iv) therapy-resistant.  These classifications are useful for determining appropriate prophylactic measurements.  No specific laboratory tests were available for the diagnosis of PLE, therefore, a clinician must rely on the clinical appearance of the disorder (e.g., clinical symptoms, the location of the lesions, the relationship of the occurrence of the lesions with sun exposure and the time course of the lesions) as well as a patient's medical history in order to make a diagnosis.  Basic preventative management of PLE consists of adequate sun protection comprising avoidance of sun exposure, the use of textile sun protection and the application of broadband sunscreens with high UVA protection potential.  Other supportive measurements have to be managed individually and are dependent on the patient's medical history and the severity of the disease.  Topical anti-oxidants, systemic immunomodulation, photo(chemo)therapy and systemic immunosuppression may be required in some cases of PLE.  Topical anti-oxidants represent a new treatment approach for moderate-to-severe PLE and are an effective and well-tolerated option for this patient population.  Severe PLE also requires photo(chemo)therapy.  Phototherapy can be in the form of 311-nm UVB or UVA1 irradiation.  In cases where 311-nm UVB or UVA1 are ineffective, psoralen plus UVA (PUVA) bath therapy may be used.  However, PUVA bath therapy must be used with caution because it is associated with acute and long-term adverse effects. In rare exceptions we would consider using oral PUVA therapy. However, in our outpatient department, quality of life of most patients is improved with the treatment regimens that are recommended for patients with moderate-to-severe PLE, without the need for photo(chemo)therapy.

An UpToDate review on “Polymorphous light eruption” (Elmets, 2013) states that that PUVA plus psoralens is considered second-line therapy for PMLE. 

First-line therapies Includes the following:

  • Sun protection -- Sun protection is first-line therapy for patients with PMLE and includes sun avoidance, sun protective clothing, and sunscreens.  Sunscreens should be broad spectrum, with both UVA and UVB protection.  A sunscreen with an SPF (sun protection factor) of at least 30 should be regularly applied.  Products containing photostabilized avobenzone or ecamsule (Mexoryl SX) offer improved protection against UVA, and have been effective in preventing PMLE eruptions.  Sunscreens that contain the non-micronized form of zinc oxide or titanium dioxide also offer photoprotection that extends throughout the UV and into the visible spectrum.  Examples of broad spectrum sunscreens containing photostabilized avobenzone or ecamsule, or zinc oxide and titanium oxide are provided.
  • Topical corticosteroids -- No randomized trials have evaluated the efficacy of topical corticosteroids for PMLE.  Clinical experience suggests that potent topical corticosteroids (groups one to three) may be used for symptomatic relief, and may be sufficient pharmacologic therapy for mild cases.  Facial lesions should be treated with lower potency topical corticosteroids (groups six to seven).

Second-line therapies include the following:

  • Phototherapy -- Prophylactic phototherapy with low dose PUVA (psoralens plus UVA) or UVB in early spring to induce tolerance to sun exposure may be an option for patients who are expected to develop significant symptoms during the spring or summer.  Treatments are usually given 2 to 3 times per week over 5 to 6 weeks.
  • PUVA therapy is superior to broadband UVB.  In one randomized trial, treatment was successful in 92 % of patients treated with PUVA, compared with 62 % of patients treated with broadband UVB.  In contrast, a small randomized trial showed narrowband UVB to be as effective as PUVA.  Because narrowband UVB is easier to administer, it is often preferred to PUVA therapy for patients with PMLE.  Narrowband UVB phototherapy can be administered 3 times per week, starting with a dose equivalent to 50 to 70 % of the MED.  The dose is increased during subsequent treatments as tolerated by the patient.

Treatment-induced exacerbations may occur early in the course of phototherapy.  If these occur, potent topical corticosteroids (groups one to three) or a short course of oral glucocorticoid therapy (e.g., prednisone 1 mg per kg for 7 to 10 days) may be required

Samson et al (2003) reviewed the evidence regarding NB-UVB for the treatment for vitiligo, pruritus, and inflammatory dermatoses.  This was a retrospective review of the treatment outcomes of 117 consecutive patients with vitiligo, pruritus, and other inflammatory dermatoses, excluding those with psoriasis and cutaneous T-cell lymphoma (CTCL), who were treated with NB-UVB between 1998 and 2001 at the authors’ institution.  Approximately 80 % of all patients showed improvement in their condition.  Narrow-band UVB phototherapy was well-tolerated, with no serious adverse effects.  In patients with vitiligo, 6.4 % had an abnormal thyroid-stimulating hormone level and 6.5 % had anemia.  The authors concluded that NB-UVB may be considered as a viable therapeutic option in the treatment of vitiligo, pruritus, and other inflammatory dermatoses.  Moreover, they stated that long-term adverse effects and cost-benefit analysis of NB-UVB therapy compared to other treatment modalities remain to be determined.

Gambichler et al (2005) provided an update on clinical experiences in NB-UVB of non-psoriatic skin conditions, and established its current position within the spectrum of competing photo(chemo)therapeutic options.  The computerized bibliographic database PubMed, without time limits, and other sources were screened for clinical trials on NB-UVB.  Included were research articles of randomized controlled trials (RCTs), open prospective studies, and retrospective observations on NB-UVB in skin disorders other than psoriasis.  A total of 28 articles met eligibility criteria including 6 RCTs, 16 open prospective studies, and 6 retrospective observations.  Narrow-band UVB is effective in patients with chronic atopic dermatitis (AD) (n = 719) and generalized vitiligo (n = 305) and appears to have some advantages over competing photo(chemo)therapeutic regimens.  Narrow-band UVB also seems to be effective in patients with PMLE (n = 25), early stages of CTCL (n = 108), chronic urticaria (n = 88), lichen planus (n = 15), pruritus associated with polycythemia vera (n = 10), seborrheic dermatitis (n = 18), actinic prurigo (n = 6), and acquired perforating dermatosis (n = 5).  The quality of evidence determined for the afore-mentioned diagnoses ranged from high to moderate to very low.  The authors concluded that the best currently available data on NB-UVB in non-psoriatic conditions exist for AD and generalized vitiligo.  In view of its efficacy, benefit/risk profile, and costs, NB-UVB may be considered the first-line photo(chemo)therapeutic option for moderately severe AD and widespread vitiligo.  In the treatment of most other non-psoriatic conditions, NB-UVB appears to be effective, but current data allow no definitive conclusions as to whether NB-UVB should be preferred to competing photo(chemo)therapeutic options such as PUVA regimens.  Because NB-UVB may have a wider indication spectrum, including AD, vitiligo, and early-stage CTCL, and appears to be equally effective or even more effective than broad-band UVB (BB-UVB), a switch from BB-UVB to NB-UVB seems to be justified.  This study had a small number of patients with PMLE (n = 25)

Pugashetti and colleagues (2010) noted that BB-UVB phototherapy has demonstrated effectiveness in the treatment of cutaneous disorders including psoriasis, AD, uremic pruritus and idiopathic pruritus.  In the last decade, there has been a rapidly escalating process of replacing BB-UVB phototherapy units with NB-UVB equipment, as studies have demonstrated that NB-UVB (ranging from 311 mm to 312 nm) is more effective in the treatment of psoriasis.  Nevertheless, it is important to recognize the efficacy of BB-UVB phototherapy in the treatment of uremic pruritus, idiopathic pruritus, eosinophilic folliculitis and other inflammatory pruritic conditions.  Furthermore, as high-lighted in this report, there was a small but significant proportion of psoriasis and AD patients who do not tolerate NB-UVB but demonstrated an excellent clinical response to BB-UVB.  It is critical for dermatologists to recognize the role of BB-UVB as a complement to NB-UVB phototherapy for patients who cannot tolerate or experience an inadequate therapeutic response from NB-UVB.  This study did not mention PMLE as an indication of BB-UVB or NB-UVB.

Walker and Jacobe (2011) stated that dermatologists are presented with a diversity of therapeutic modalities for the treatment of inflammatory, sclerosing, and neoplastic conditions, but with the development of various new irradiation devices that utilize specific parts of the electromagnetic spectrum, phototherapy has become a more viable, accessible, and effective option in the treatment of these conditions.  The UV range (10 to 400 nm) is further sub-divided into UVA and UVB, each of which has been particularly useful in a number of skin conditions.  The most commonly used forms of UV irradiation are UVA1, PUVA, and NB-UVB.  Each of these modalities differ in their mechanism of action, indications, and side effect profiles, and it is important that clinicians be familiar with these differences.  Today, phototherapy is a valuable option in the treatment of many non-psoriatic conditions including AD, sclerosing skin conditions such as morphea, vitiligo, and mycosis fungoides.  Due to its relative safety, phototherapy may be used in most populations, including children and pregnant women.  However, contraindications and side effects are known and should be considered before patients begin a phototherapeutic regimen.  Again, this study did not mention PMLE as an indication of BB-UVB or NB-UVB.

Veith et al (2011) noted that phototherapy is used for the medical care of cutaneous conditions that do not respond to topical or systemic medical agents, and for conditions that require broad exposure to UV as a stabilizing agent for disease.  Numerous wavelengths and delivery devices of UV light are used in childhood.  This article was a brief overview of the medical usage of phototherapy in childhood.  In the neonatal nursery blue light (459 to 460 nm) is used to reduce bilirubin levels and prevent kernicterus.  While PUVA has been demonstrated to be effective in a variety of pediatric skin conditions, NB-UVB therapy (311 nm) has largely replaced PUVA as initial choice in full-body phototherapy for children.  The latter is easier to deliver, with less resultant erythema than systemic PUVA, which requires strict use of 24-hour protective eyewear.  Narrowband-UVB is therefore preferred for stabilization and clearance of a variety of inflammatory and autoimmune conditions especially AD, psoriasis and vitiligo.  Conditions with lymphocytic infiltration, including mycosis fungoides, alopecia areata and pityriasis lichenoides can improve with NB-UVB as well.  Alternatively, localized delivery of NB-UVB can be performed using the Excimer laser (308 nm), which has been described for the therapy of vitiligo and alopecia areata in childhood.  Some diseases with dermal infiltration including morphea and mastocytosis may do better with PUVA or UVA1.  Delivery of psoralens can also be performed topically for said conditions and in the setting of alopecia areata, thereby limiting UVA exposure, while retaining efficacy.  Phototherapy can be a helpful adjunct in pediatric skin disease, but is limited by compliance issues.  Parents can act as partners in the safe and effective delivery of phototherapy by standing outside the booth or inside with the child to ensure lack of movement and to aid in maintenance of eyewear.  Choice of type of phototherapy and close monitoring, with parental partnership, is the key to successful treatment.  Again, this study did not mention PMLE as an indication of BB-UVB or NB-UVB.

Also, an UpToDate review on “Polymorphous light eruption” (Elmets, 2013) does not mention the use of photochemotherapy/Goeckerman treatment as therapeutic options.  The review provides several “Summary and Recommendations”:

  • UVA is the most common inciting spectrum of light, but UVB and visible light may also provoke PMLE in some patients
  • Primary treatment for PMLE includes sun avoidance, sun-protective clothing, and sunscreen.  Broad spectrum sunscreens with an SPF of at least 30 should be regularly used
  • For patients with active lesions, we suggest treatment with potent topical corticosteroids (groups one to three).  An alternative in patients with infrequent exacerbations, particularly those who require rapid improvement, is a short course of systemic glucocorticoids
  • For patients who develop frequent exacerbations during the spring and summer, we suggest prophylactic phototherapy in early spring
  • Juvenile spring eruption is a variant of PMLE that is manifested by erythematous papules or bullae typically on ears of children or adolescents after sun exposure.  Symptoms are self-limited and resolve within several weeks

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.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
PUVA:
CPT codes covered if selection criteria are met:
96912
96913
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus [HIV] disease
202.10 - 202.18 Mycosis fungoides [cutaneous T-cell lymphoma]
238.4 Polycythemia vera
279.50 - 279.53 Graft-versus-host disease
691.8 Other atopic dermatitis and related conditions [severe refractory]
692.72 Acute dermatitis due to solar radiation
696.1 Other psoriasis [severe disabling, involving 10% or more of body or severe psoriasis involving the hands, feet or scalp]
696.2 Parapsoriasis [severe] [pityriasis lichenoides]
697.0 Lichen planus [severe]
701.0 Circumscribed scleroderma [morphea]
704.01 Alopecia areata
709.01 Vitiligo
757.33 Congenital pigmentary anomalies of skin [severe urticaria pigmentosa]
996.85 Complications of bone marrow transplant [skin conditions]
ICD-9 codes not covered for indications listed in CPB (not all-inclusive):
277.39 Other amyloidosis [lichen amyloidosis]
697.8 Other lichen, not elsewhere classified [lichen amyloidosis]
701.8 Other specified hypertrophic and atrophic conditions of skin [lichen myxedematosus]
706.0 - 706.1 Acne
709.09 Other dyschromia [melasma]
757.39 Other specified anomalies of skin [Darier disease]
Other ICD-9 codes related to the CPB:
686.8 - 686.9 Other and unspecified local infection of skin and subcutaneous tissue [chronic palmoplantar pustulosis]
695.89 Other specified erythematous conditions [granuloma annulare]
698.8 Other specified pruritic conditions [pruritic eruptions of HIV infection]
704.8 Other specified diseases of hair and hair follicles [eosinophilic folliculitis]
709.3 Degenerative skin disorders [necrobiosis lipoidica]
ICD-9 codes contraindicated for this CPB:
172.0 - 173.9 Malignant neoplasm of skin [melanoma or other skin cancer]
630 - 679.14 Complications of pregnancy, childbirth, and the puerperium
692.82 Dermatitis due to other radiation [history of ionizing radiation exposure]
909.2 Late effect of radiation [history of ionizing radiation exposure]
961.1 Poisoning by arsenical anti-infectives [history of arsenic exposure]
985.1 Toxic effect of arsenic and its compounds [history of arsenic exposure]
990 Effects of radiation, unspecified [history of ionizing radiation exposure]
V10.82 Personal history of malignant melanoma of skin
V10.83 Personal history of other malignant neoplasm of skin
V22.0 - V23.9 Supervision of pregnancy
UVA/UVB and UVB with the addition of topical coal tar (also known as the Goeckerman regimen) or petrolatum:
CPT codes covered if selection criteria are met:
96900
96910
96913
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus [HIV] disease
202.10 - 202.18 Mycosis fungoides [cutaneous T-cell lymphoma]
691.8 Other atopic dermatitis and related conditions [severe refractory]
692.9 Contact dermatitis and eczema of unspecified cause
696.1 Other psoriasis
696.2 Parapsoriasis [pityriasis lichenoides]
696.3 Pityriasis rosea
697.0 Lichen planus
701.0 Circumscribed scleroderma [only UVA is covered for morphea - not UVB]
704.01 Alopecia areata
705.81 Dyshidrosis
706.0 - 706.1 Acne
709.01 Vitiligo
757.33 Congenital pigmentary anomalies of skin
996.85 Complications of bone marrow transplant [skin conditions]
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
370.00 - 370.9 Keratitis [infectious]
694.2 Juvenile dermatitis herpetiformis
694.5 Pemphigoid
694.60 Benign mucous membrane pemphigoid without mention of ocular involvement
694.61 Benign mucous membrane pemphigoid with ocular involvement
698.0 - 698.9 Puritis
705.83 Hidradenitis [hidradenitis suppurativa]
710.1 Systemic sclerosis
778.1 Sclerema neonatorum
Other ICD-9 codes related to the CPB:
704.8 Other specified diseases of hair and hair follicles [eosinophilic folliculitis]
709.8 Other specified disorders of skin [photodermatoses] [lymphomatoid papulosis]
Home phototherapy (UVB treatment)(not covered for home PUVA):
HCPCS codes covered if selection criteria are met:
A4633 Replacement bulb/lamp for ultraviolet light therapy system, each
E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; 4 ft panel
E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; 6 ft panel
E0694 Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer and eye protection
ICD-9 codes covered if selection criteria are met:
696.1 Other psoriasis [severe/ with frequent flares/ needing to initiate therapy immediately/ unable to attend on-site therapy]
Narrow Band UVB:
There are no specific codes for narrow band UVB:
ICD-9 codes covered if selection criteria are met:
202.10 - 202.18 Mycosis fungoides [early state]
691.8 Other atopic dermatitis and related conditions [atopic eczema]
696.1 Other psoriasis
692.72 Acute dermatitis due to solar radiation
709.01 Vitiligo
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
279.50 - 279.53 Graft-versus-host disease
576.8 Other specified disorders of biliary tract [cholestasis of pregnancy]
692.0 - 692.6 Contact dermatitis and other eczema [chemical]
692.89-692.9 Contact dermatitis and other eczema due to other and unspecified causes [superficial mixed-cell dermatitis]
695.89 Granuloma annulare
698.0 - 698.9 Pruritis
708.3 Dermatographic urticaria
709.00 Dyschromia [skin hypo-pigmentation from scarring]
709.09 Other dyschromia [melasma][ progressive macular hypomelanosis]
701.0 Circumscribed scleroderma [Morphea]
705.83 Hidradenitis [hidradenitis suppurative]
708.8 Other specified urticaria [papular]
710.1 Systemic sclerosis [scleroderma]


The above policy is based on the following references:
  1. American Academy of Dermatology Committee on Guidelines of Care. Guidelines of care for phototherapy and photochemotherapy. J Am Acad Dermatol. 1994;31(4):643-648.
  2. Storbeck K, Holzle E, Schurer N, et al. Narrow-band UVB (311 nm) versus conventional broad-band UVB with and without dithranol in phototherapy for psoriasis. J Am Acad Dermatol. 1993;28(2 Pt 1):227-231.
  3. Taylor CR, Hawk JL. PUVA treatment of alopecia areata partialis, totalis and universalis: Audit of 10 years' experience at St. John's Institute of Dermatology. Br J Dermatol. 1995;133(6):914-918.
  4. Vogelsang GB, Wolff D, Altomonte V, et al. Treatment of chronic graft-versus-host disease with ultraviolet irradiation and psoralen (PUVA). Bone Marrow Transplant. 1996;17(6):1061-1067.
  5. Momtaz K. The benefits and risks of long-term PUVA photochemotherapy. Dermatol Clin. 1998;16(2):227-234.
  6. Zanolli MD. Psoriasis and Reiter's syndrome. In: Principles and Practice of Dermatology. 2nd ed. WM Sams Jr, PJ Lynch, eds. New York, NY: Churchill Livingstone Inc.; 1996:353-354.
  7. Alabdulkareem AS, Abahussein AA, Okoro A. Minimal benefit from photochemotherapy for alopecia areata. Int J Dermatol. 1996;35(12):890-891.
  8. Honig B, Morison WL, Karp D. Photochemotherapy beyond psoriasis. J Am Acad Dermatol. 1994;31(5):775-790.
  9. Davis MD, McEvoy MT, el-Azhary RA. Topical psoralen-ultraviolet A therapy for palmoplanar dermatoses: Experience with 35 consecutive patients. Mayo Clin Proc. 1998;73(5):407-411.
  10. Gordon PM, Diffey BL, Matthews JN, Farr PM. A randomized comparison of narrow-band TL-01 phototherapy and PUVA photochemotherapy for psoriasis. J Am Acad Dermatol. 1999;41(5 Pt 1):728-732.
  11. Griffiths CE, Clark CM, Chalmers RJ, et al. A systematic review of treatments for severe psoriasis. Health Technol Assess. 2000;4(40):1-125.
  12. Dutz J. Treatment options for localized scleroderma. Skin Therapy Lett. 2000;5(2):3-5.
  13. Hawk A, English JC 3rd. Localized and systemic scleroderma. Semin Cutan Med Surg. 2001;20(1):27-37.
  14. Sapadin AN, Fleischmajer R. Treatment of scleroderma. Arch Dermatol. 2002;138(1):99-105.
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  17. Wolff K. Treatment of cutaneous mastocytosis. Int Arch Allergy Immunol. 2002;127(2):156-159.
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  19. George SA, Bilsland DJ, Johnson BE, Ferguson J. Narrow-band (TL-01) UVB air-conditioned phototherapy for chronic severe adult atopic dermatitis. Br J Dermatol. 1993;128(1):49-56.
  20. Grundmann-Kollmann M, Behrens S, Podda M, et al. Phototherapy for atopic eczema with narrow-band UVB. J Am Acad Dermatol. 1999;40(6 Pt 1):995-997.
  21. Der-Petrossian M, Seeber A, Honigsmann H, Tanew A. Half-side comparison study on the efficacy of 8-methoxypsoralen bath-PUVA versus narrow-band ultraviolet B phototherapy in patients with severe chronic atopic dermatitis. Br J Dermatol. 2000;142(1):39-43.
  22. Reynolds NJ, Franklin V, Gray JC, et al. Narrow-band ultraviolet B and broad-band ultraviolet A phototherapy in adult atopic eczema: A randomised controlled trial. Lancet. 2001;357(9273):2012-2016.
  23. Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol. 2004;50(3):391-404.
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  25. Griffiths CE, Clark CM, Chalmers RJ, et al. A systematic review of treatments for severe psoriasis. Health Technol Assess. 2000;4(40:1-125.
  26. Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess. 2000;4(37):1-191. 
  27. Clark C, Dawe RS, Evans AT, et al. Narrowband TL-01 phototherapy for patch-stage mycosis fungoides. Arch Dermatol. 2000;136:748-752.
  28. Hofer A, Cerroni L, Kerl H, Wolf P. Narrowband (311-nm) UVB therapy for small plaque parapsoriasis and early-stage mycosis fungoides. Arch Dermatol. 1999;135:1377-1380.
  29. Gathers RC, Scherschun L, Malick F. Narrowband UVB phototherapy for early-stage mycosis fungoides. J Am Acad Dermatol. 2002;47(2 Pt.1):191-197.
  30. Diederen P, van Weelden H, Sanders C, et al. Narrowband UVB and psoralen-UVA in the treatment of early-stage mycosis fungoides: A retrospective study. J Am Acad Dermatol. 2003;48(2 Pt. 1):215-219.
  31. Whittaker SJ, Marsden JR, Spittle M, Russell Jones R. Joint British Association of Dermatologists and U.K. Cutaneous Lymphoma Group guidelines for the management of primary cutaneous T-cell lymphomas. Br J Dermatol. 2003;149(6):1095-1107.
  32. Sullivan TJ. Managed care’s perspective on treatment of psoriasis. Managed Care. 2003;12(5 Suppl):14-17.
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  35. Klecz RJ, Schwartz RA. Pruritus. Am Fam Physician. 1992;45(6):2681-2686.
  36. Menage HD, Norris PG, Hawk JL, Graves MW. The efficacy of psoralen photochemotherapy in the treatment of aquagenic pruritus. Br J Dermatol. 1993;129(2):163-165.
  37. Brenner M, Herzinger T, Berking C, et al. Phototherapy and photochemotherapy of sclerosing skin diseases. Photodermatol Photoimmunol Photomed. 2005;21(3):157-165.
  38. Morison WL, Nesbitt JA 3rd.  Oral psoralen photochemotherapy (PUVA) for pruritus associated with polycythemia vera and myelofibrosis [letter]. Am J Hematol. 1993;42(4):409-410.
  39. Jeanmougin M, Rain JD, Najean Y. Efficacy of photochemotherapy on severe pruritus in polycythemia vera. Ann Hematol. 1996;73(2):91-93.
  40. Swerlick RA. Photochemotherapy treatment of pruritus associated with polycythemia vera. J Am Acad Dermatol. 1985;13(4):675-677.
  41. Whitton ME, Ashcroft DM, Barrett CW, Gonzalez U. Interventions for vitiligo. Cochrane Database Syst Rev. 2006;(1):CD003263.
  42. Chan ES-Y, Thornhill M, Zakrzewska J. Interventions for treating oral lichen planus. Cochrane Database Syst Rev. 1999;(2):CD001168.
  43. Chalmers RJG, O'Sullivan T, Owen CM, Griffiths CEM. Interventions for guttate psoriasis. Cochrane Database Syst Rev. 2000;(2):CD001213.
  44. McMullin MF, Bareford D, Campbell P, et al. General Haematology Task Force, British Committee for Standards in Haematology. Guidelines for the Diagnosis, Investigation and Management of Polycythaemia/Erythrocytosis. London, UK: British Society for Haematology; 2005.
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  47. Cooper SM, Burge SM. Darier's disease: Epidemiology, pathophysiology, and management. Am J Clin Dermatol. 2003;4(2):97-105.
  48. Ellis E, Scheinfeld N. Eosinophilic pustular folliculitis: A comprehensive review of treatment options. Am J Clin Dermatol. 2004;5(3):189-197.
  49. Calzavara-Pinton P, Venturini M, Sala R. Medium-dose UVA1 therapy of lymphomatoid papulosis. J Am Acad Dermatol. 2005;52(3):530-532.
  50. Koreck AI, Csoma Z, Bodai L, et al. Rhinophototherapy: A new therapeutic tool for the management of allergic rhinitis. J Allergy Clin Immunol. 2005;115(3):541-547.
  51. Koek MB, Buskens E, Bruijnzeel-Koomen CA, Sigurdsson V. Home ultraviolet B phototherapy for psoriasis: Discrepancy between literature, guidelines, general opinions and actual use. Results of a literature review, a web search, and a questionnaire among dermatologists. Br J Dermatol. 2006;154(4):701-711.
  52. Narbutt J, Torzecka JD, Sysa-Jedrzejowska A, Zalewska A. Long-term results of topical PUVA in necrobiosis lipoidica. Clin Exp Dermatol. 2006;31(1):65-67.
  53. Beattie PE, Dawe RS, Ibbotson SH, Ferguson J. UVA1 phototherapy for treatment of necrobiosis lipoidica. Clin Exp Dermatol. 2006;31(2):235-238.
  54. De Rie MA, Sommer A, Hoekzema R, Neumann HA. Treatment of necrobiosis lipoidica with topical psoralen plus ultraviolet A. Br J Dermatol. 2002;147(4):743-747.
  55. Marsland AM, Chalmers RJG, Hollis S, et al. Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev. 2006;(1):CD001433.
  56. Ferrandiz C, Carrascosa JM, Just M, et al. Sequential combined therapy with thalidomide and narrow-band (TL01) UVB in the treatment of prurigo nodularis. Dermatology. 1997;195(4):359-361.
  57. Delrosso G, Bornacina C, Farinelli P, et al. Bath PUVA and psoriasis: Is a milder treatment a worse treatment? Dermatology. 2008;216(3):191-193.
  58. Ghoreschi K, Thomas P, Penovici M, et al. PUVA-bath photochemotherapy and isotretinoin in sclerodermatous graft-versus-host disease. Eur J Dermatol. 2008;18(6):667-670.
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  60. Pichon-Riviere A, Augustovski F, Garcia Marti S, et al. PUVA therapy: Main dermatology applications [summary]. IRR No. 167. Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (IECS); April 2009.
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  62. Cyr PR. Diagnosis and management of granuloma annulare. Am Fam Physician. 2006;74(10):1729-1734.
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  67. Suh KS, Kang JS, Baek JW, et al. Efficacy of ultraviolet A1 phototherapy in recalcitrant skin diseases. Ann Dermatol. 2010;22(1):1-8.
  68. Khan YA, Kashiwabuchi RT, Martins SA, et al. Riboflavin and ultraviolet light a therapy as an adjuvant treatment for medically refractive acanthamoeba keratitis: Report of 3 cases. Ophthalmology. 2011;118(2):324-331.
  69. Lowe NJ. Home ultraviolet phototherapy. Semin Dermatol. 1992;11(4):284-286.
  70. van Coevorden AM, Kamphof WG, van Sonderen E, et al. Comparison of oral psoralen-UV-A with a portable tanning unit at home vs hospital-administered bath psoralen-UV-A in patients with chronic hand eczema: An open-label randomized controlled trial of efficacy. Arch Dermatol. 2004;140(12):1463-1466.
  71. Kreutz M, Karrer S, Hoffmann P, et al. Whole-body UVB irradiation during allogeneic hematopoietic cell transplantation is safe and decreases acute graft-versus-host disease. J Invest Dermatol. 2012;132(1):179-187.
  72. Duarte I, Nina BI, Gordiano MC, et al. Progressive macular hypomelanosis: An epidemiological study and therapeutic response to phototherapy. An Bras Dermatol. 2010;85(5):621-624.
  73. Ko MJ, Yang JY, Wu HY, et al. Narrowband ultraviolet B phototherapy for patients with refractory uraemic pruritus: A randomized controlled trial. Br J Dermatol. 2011;165(3):633-639.
  74. Kreutz M, Karrer S, Hoffmann P, et al. Whole-body UVB irradiation during allogeneic hematopoietic cell transplantation is safe and decreases acute graft-versus-host disease. J Invest Dermatol. 2012;132(1):179-187.
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  76. Kim MB, Kim GW, Cho HH, et al. Narrowband UVB treatment of progressive macular hypomelanosis. J Am Acad Dermatol. 2012;66(4):598-605.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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