LEARNING MODULE FOR PHOTOTHERAPY CC 50-020
Developed by:
Bernadette Ingersoll, Ph.T., Phototherapy Technician Nancy Fox RN, Clinical Nurse Educator
Date: Revised:
April, 2005 January, 2011
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
TABLE OF CONTENTS
Purpose………………………………………………………………………………
3
Learning Objectives…………………………………………………………………
3
Method………………………………………………………………………………... 3 Theory………………………………………………………………………………… 4 Required Readings………………………………………………………………….. 6 References…………………………………………………………………………… 7 Appendices Appendix A: Assessment Guidelines……………………………………… 9 Appendix B: Photosensitizing Medications……………………………….. 13 Appendix C: Skin Type Estimation………………………………………… 17 Appendix D: Guidelines to Erythema Assessment………………………. 18 Appendix E: Guidelines for Pruritus Assessment………………………... 21 Appendix F: Assessment of Response to UVL Therapy………………... 22 Appendix G: Treatment Protocol for Broad Band UVB………………….
23
Appendix H: Treatment Protocols for NBUVB……………………………
26
Appendix I: Treatment Protocol for UVA………………………………….. 27 Appendix J: PUVA Photochemotherapy…………………………………..
29
Test……………………………………………………………………………………
32
Proficiency Standard Skills Checklist(s)…………………………………………..
42
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 3 of 44
PURPOSE Phototherapy in a dermatology practice enables practitioners to provide a broader range of therapeutic options to patients with severe skin disease. Phototherapy is exposure to ionizing radiation, ultraviolet light (UVL), for therapeutic benefit. It may involve exposure to UVA, UVB or various combinations of both types of radiation. Photochemotherapy is the therapeutic use of radiation in combination with a photosensitizing chemical. It currently involves the use of psoralens and UVA radiation (PUVA). Treatment with these modalities may involve partial or whole body exposure. Ultraviolet light has a diagnostic application as well. It is utilized in Photopatch testing for allergies and Photosensitivity testing. Both are performed by a certified phototherapy technician. The safe and effective use of phototherapy and psoralen photochemotherapy requires that the phototherapy technician (PhT) reach and maintain an expected level of competence in performing this Delegated Medical Function. Completion of the Learning Module on Phototherapy provides the PhT with the theory and skills necessary to perform this Delegated Medical Function. After completing the learning objectives, the phototherapy technician will demonstrate competency according to the proficiency standards skills checklist.
LEARNING OBJECTIVES Following the completion of this learning module, the PhT will be able to: 1. Discuss indications for phototherapy, photosensitivity testing and photopatch testing. 2. Determine skin type of the patient. 3. Determine initial treatment doses as per specific treatment protocols. 4. Determine subsequent treatment doses following assessments of erythema, pruritus, response to UVL treatment and according to the specific treatment protocol. 5. Complete the proficiency standards skills checklist with 100% accuracy. METHOD To complete the learning module, the PhT will: 1. Complete the theory/required readings. 2. Review the policy and procedure: Phototherapy. 3. Complete the test. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 4 of 44
4. Observe PhT competent in this procedure. 5. Perform the procedure according to the proficiency standards skills checklist under the supervision of the PhT until determination of competency by certified staff. THEORY Ultraviolet radiation/ultraviolet light is expressed in wavelengths of electromagnetic energy and the measure of the distance between 2 points of the wavelength is called a nanometer (nm). Ultraviolet Light (UVL) is that part of the electromagnetic spectrum that begins next to the violet end of the color spectrum (400 nm) and extends to the beginning of the x-ray region (200 nm). UVL causes many profound biologic changes, including temporary suppression of epidermal basal cell division, followed by increased cell turnover and UVL-induced immune suppression. It is often used in the treatment of psoriasis, mycosis fungoides, vitiligo and chronic eczematous eruptions, as well as renal or liver induced pruritus. UVL spectrum is subdivided into three bands: UVC (200 to 290), UVB (290 to 320), and UVA (320 to 400). Sunlight is the optimal source of ultraviolet light. It is the least expensive and most effective under most circumstances. The ozone layer in the upper atmosphere acts as a filter and absorbs virtually all UVL shorter than 290 nm – all of the UVC radiation, so only UVB and UVA rays reach the earth’s surface. The disadvantages of sunlight radiation are its variable absorption by clouds and the difficulty in controlling or monitoring its intensity. To overcome these disadvantages artificial light sources were developed. (Arndt and Bowers, 2002) The positive effects of UV radiation include vitamin D metabolism and phototherapy of cutaneous diseases. A number of diseases are responsive to UV radiation alone or in combination with a photosensitising medication (photochemotherapy). The beneficial effects of UV radiation must be weighed against the potential adverse effects, which include sunburn, photoaging, and carcinogenesis of the skin. UVB radiation is responsible for most of the therapeutic benefit of sunlight and conventional artificial UVL therapy. UVB dose depends on the skin type; skin type depends on the inherent melanin content, as well as the genetic capacity of the skin to tan. (Lookingbill & Marks, 1993) Daily exposures of UVB should be regulated so as not to produce burns. A mild transient erythema is desirable. The time of exposure can be slowly increased by a few seconds each treatment. After clearing of the skin has been achieved, maintenance UVB phototherapy contributes to the duration of the remission and is beneficial for many patients. While the goal of phototherapy is to deliver enough UVL to be therapeutic, it is important to keep lifetime UVL exposure to a minimum. Various types of shielding are used during phototherapy to protect areas of the body that do not require treatment e.g. sunblocks, sunscreens, drapes and protective eyewear.(Klotz, Ursel and Ingersoll) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 5 of 44
Narrow Band UVB (311 nm), a selective narrow ultraviolet wavelength, is very effective in the treatment of psoriasis. UVA radiation from sunlight or fluorescent bulbs will not, by itself, cause erythema or pigmentation except with extremely large doses. However, in the presence of photosensitizing agents such as psoralen compounds, this UVL wavelength becomes an excellent therapeutic tool. The combination of light and photosensitizing agent is termed photochemotherapy or PUVA (psoralen plus UVA) therapy. This results in transient inhibition of DNA synthesis as well as alterations of immune reactivity. PUVA treatment is useful in severe psoriasis and is also effective for some patients with vitiligo and mycosis fungoides. It is sometimes helpful in treating atopic dermatitis and other inflammatory dermatoses. (Arndt and Bowers, 2002). Oral psoralen should be taken 2 hours prior to light exposure. Topical psoralen should be applied 1 ½ - 2 hours prior to UVA. A bath or soak, containing psoralen is used for 10 minutes and is a safe and effective form of therapy. The UVA must be administered to the patient within 25 minutes of their bath or soak. Short- term side effects of oral PUVA include tanning, pruritus, nausea, headache, and dizziness. Long-term effects include cataracts, lentignes, photoaging, squamous cell carcinoma, and melanoma. (Arndt and Bowers, 2002). Each type of UVL produces a different biologic response. Therefore it is important to give the right type and amount of light energy. This biologic response, photobiology, is the result of photochemistry. Photochemistry occurs when light energy (photons) is absorbed by a molecule. This absorption by the molecule is very specific as certain wavelengths can only be absorbed by specific molecular structures.
Radiometry and Dosimetry Light energy is expressed as joules per time or joules/second. Power is expressed in units: watts per area/cm². Intensity is an amount of energy in a given area and is expressed as watts/cm². Joule= 1watt/sec Energy (joule) = power (watt) x exposure time (second).
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 6 of 44
A radiometer is used to determine the wavelengths of an artificial light source. A radiometer with filters is designed to “read” the type of the wavelengths of the light bulbs in the unit. The radiometer also measures the output or power of the lamp. This can change over time with use (hours) and with fluctuations in the electrical current. Irradiance is the radiant power per unit area (measured by the radiometer) and is measured in watts/cm². The reading is influenced by the distance the radiometer and probe are from the light source. Exposure dose is equal to irradiance multiplied by the amount of time. Exposure Dose = intensity x time Units of dose: UVA is Joules/cm² UVB is milliJoules/cm² Narrow Band UVB is milliJoules/cm²
REQUIRED READINGS 1. Klotz, J., Ursel, K.R., Ingersoll, B. (2002). Description of Common Dermatological Lesions. Phototherapy. (pp. 8-13). (Available from Division of Dermatology, QEII Health Sciences Centre, Halifax, Nova Scotia,) 2. Klotz, J., Ursel, K.R., Ingersoll, B. (2002). Function and Structure of the Skin. Phototherapy. (pp. 4-8). (Available from Division of Dermatology, QEII Health Sciences Centre, Halifax, Nova Scotia,) 3. Dermatology Nurses' Association Education Task Force. (1999). Cutaneous Effects of UVL. DNA Phototherapy Administration Symposium. (pp. 4-11) Leach,E.E (Ed.).Dermatology Nurses’ Association Education Task Force. 4. Dermatology Nurses' Association Education Task Force. (1999). Metering and Shielding. DNA Phototherapy Administration Symposium. (pp. 121-127) Leach, E.E (Ed.).Dermatology Nurses’ Association Education Task Force. 5. Marks, J.G., DeLeo, V.A. (1997). Photoallergens. In Contact and Occupational Dermatology. (2nd edition. Pp 200-208). St.Louis; Mosby 6. Rietschel, R.L., Fowler, J.F.(1995) Contact Photodermatitis. In Fischer’s Contact Dermatitis. (4th edition, pp524-529). Baltimore: Williams and Wilkins. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 7 of 44
7. Leach, E., Morgan, P., McClelland, P., Shelk, J. Basic Principles of Photobiology and Photochemistry for Nurse Phototherapists and Phototechnicians. In: Dermatology Nurses’ Association 27th Annual Convention. (2009) Fundamentals of Photobiology: The Joan Shelk Memorial Workshop.
REFERENCES American Academy of Dermatology. (1994). Guidelines of Care for Phototherapy and Photochemotherapy. Journal of American Academy of Dermatology, 31, 643-648. Arndt,K., Bowers,K. (2002). Manual Of Dermatologic Therapeutics (6th ed.). Philaadelphia, PA: Lippincott, Williams & Wilkins. Bodom,R., James,W., Berger,W. (2000 ). "Andrews' Diseases of the Skin" Clinical Dermatology (9th ed.). : WB Saunders. Dermatology Nurses' Association Education Task Force. (1999). DNA Phototherapy Administration Symposium. Leach,E.E (Ed.).Dermatology Nurses’ Association Education Task Force. Dermatology Nurses’ Association 27th Annual Convention. (2009). Fundamentals of Photobiology: The Joan Shelk Memorial Workshop. Brown, B., McLelland, P., Morgan, P., Nicholson, M. (Editors).Dermatology Nurses’ Association. Fitzpatrick,T.B., Johnson,R., Wolff,K., Suurmond,D. (2001). Color Atlas and Synopsis of Clinical Dermatology (4th ed.). New York: McGraw-Hill . Gawkrodger, David. (2008). Dermatology: An Illustrated Colour Text (4th ed.).Toronto: Churchill Livingstone. Hawk, J., Ferguson, J. (2008). Abnormal Responses to Ultraviolet Radiation: Idiopathic, Probably Immunologic, and Photo-Exacerbated. In Fitzpatrick’s Dermatology in General Medicine (7th ed., Vol. I, pp. 816-827). New York: McGraw-Hill. Hönigsmann et al. (2008). Photochemotherapy and Photodynamic Therapy. In Fitzpatrick’s Dermatology in General Medicine (7th ed., Vol. II, pp. 2249-2262). New York: McGraw-Hill. Klotz, J., Ursel, K.R., Ingersoll, B. (2002). Phototherapy. (Available from Division of Dermatology, QEII Health Sciences Centre, Halifax, Nova Scotia,) Krutmann,J., Morita, A. (2008 ). Therapeutic Photomedicine; Phototherapy. In Fitzpatrick’s Dermatology in General Medicine (7th ed., Vol. II, pp. 2243-2248). New York: McGraw-Hill. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 8 of 44
Leach, E., Morgan, P., McClelland, P., Shelk, J. Basic Principles of Photobiology and Photochemistry for Nurse Phototherapists and Phototechnicians. In: Dermatology Nurses’ Association 27th Annual Convention. (2009) Fundamentals of Photobiology: The Joan Shelk Memorial Workshop. Lim, H. (2008). Abnormal Responses to Ultraviolet Radiation: Photosensitivity Induced by Exogenous Agents. In Fitzpatrick’s Dermatology in General Medicine (7th ed., Vol. I, pp. 828-834). New York: McGraw-Hill. Lookingbill, D.P., Marks, J.G. (1993). Principles of Dermatology (2nd ed.). : WB Saunders Co. Marks, J.G., DeLeo, V.A. (1997). Photoallergens. In Contact and Occupational Dermatology. (2nd edition. pp 200-208). St.Louis;Mosby Moore,D.E. (2002). Drug-Induced Cutaneous Photosensitivity. Drug Safety 2002 (Vol. 25 (5), pp. 345-372). : Adis International Ltd. Pathak, M., Young, A., Walker, S. (2008). Acute and Chronic Effects of Ultraviolet Radiation on the Skin. In Fitzpatrick’s Dermatology in General Medicine (7th edition, Vol. I, pp. 809-815). New York: McGraw-Hill. Rietschel, R.L., Fowler, J.F.(1995) Contact Photodermatitis. In Fischer’s Contact Dermatitis. (4th edition, pp 524-529). Baltimore: Williams and Wilkins. Stern,R.S., Nichols, K.T., Vakeva, L.H. (1997). Malignant Melanoma in Patients Treated for Psoriasis with Methoxsalen (Psoralen) and Ultraviolet A Radiation(PUVA). New England Journal of Medicine. (Vol. 336 (15), pp1041-1045.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 9 of 44
APPENDIX A Assessment Guidelines A. Subjective Data Quality of life studies show that living with skin disease (psoriasis) can be far more devastating to a patient’s life than cardiac disease, respiratory disease, cancer and arthritis. These patients deal with issues such as social isolation, low self-esteem, depression, establishing and maintaining intimacy in relationships, physical discomfort and joblessness if the skin condition is visible. 1. Assess the individual’s perception of the disease. a) What do they know about the disease? b) How do they feel it affects their appearance? 2. Assess the psychological effect of the disease upon the individual. a) Is the disease process affecting their lifestyle? b) Are they anxious or depressed? 3. Assess the “family unit”. a) Is the family supportive of the patient? b) Are there stressors in the family relationships? 4. Assess the individual’s ability to function in society. a) How is this affecting their relationship with others? b) Have they ever worked, and if so, are they able to continue work? c) Will they need any forms filled out for their employer while they are receiving treatment? d) Have they developed effective coping mechanisms? B. Objective Data 1. From the consult: a) Patient identification (age, sex, DOB, NS Health Care Information, HUN) address and contact numbers. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 10 of 44
b) Diagnosis c) Treatment ordered by Dermatologist
2. History of Present Illness (HPI) a) Onset of the disease b) Course of the disease (exacerbations and remissions) c) Past treatments: medical, UVL treatments 3. Past Medical History (PMH) / Associated medical problems a) Diabetes b) Arthritis, cardiovascular, pulmonary, etc. c) Skin cancers. This will include pre-malignant actinic keratoses or malignant skin tumors. 4. Medications (see Appendix B) a) Past and present use of photosensitizing agents. b) Note the medications patient is on for the duration of the treatment. c) Advise patient to notify phototherapy technician of any medication changes or additions. 5. Determine the Skin Type (see Appendix C). Your initial dose of UVL will depend on this assessment. 6. Note the general distribution and severity of lesions. 7. Note other significant physical and psychological problems. Some patients have severe arthritis and may be unable to stand for long periods. Other patients are claustrophobic and may be unable to tolerate treatment in the cabinet. These problems must be taken into consideration when planning treatment and should be brought to the physician’s attention. C. Plan 1. Review data. 2. Summarize problems. 3. Note any precautions in a prominent place in the patient record. 4. Compare findings from all sources. Are the patient’s descriptions of symptoms This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 11 of 44
consistent with objective findings? How are current findings related to previous health history? 5. Indicate the treatment or planned progress on the treatment regime. 6. Review the process in detail with the patient. Identify patient concerns as well as patient goals. D. Implementation and Evaluation 1. Begin patient teaching; offer patient educational material, hints, tips and suggestions that will improve treatment outcomes. 2. On every subsequent clinic visit for treatment, a skin assessment is completed. The erythematic response of a patient to light determines whether treatment will continue as per protocol or if adjustments need to be made. The dermatologist may have to reassess the patient in certain situations (severe erythema, burns or itch) if a problem has arisen. Ongoing assessment: a) Was there any reaction after the last treatment? b) Was there any discomfort, erythema or pruritus? Did they notice any blisters? Were there any symptoms of a fever or chills? c) If yes, when did it occur? How long did it last? What was the degree of discomfort? d) What did the patient do about it? Did they apply creams, take baths, seek help from a physician or just leave the condition alone. e) Discuss the patient’s progress with him. Offer words of encouragement and praise for compliance. Evaluate response to therapy: 1. Evaluate erythema. a) Is there erythema present at treatment time? b) Was there erythema after the last treatment? How long did it last? c) What was the previous UVL dose? Was the increase too much? d) Was the time span between treatments longer than usual? e) Is the patient taking any new medications? f) Look for improvements or flare-ups. 2. Evaluate pruritus. a) When did it begin? This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 12 of 44
b) Is it located on involved skin or is it generalized? c) Is it accompanied by erythema? d) Did it exist before phototherapy? If so, does it feel the same or different? e) Does it feel prickly? Does it feel deep? Patient can’t get to it. PUVA can cause a very severe deep-seated “PUVA itch”. It is also very hard to treat and may persist long after PUVA has been discontinued. Look for improvement or flare-up of disease: a) Are lesions less or more scaly? b) Are plaques thinning? Beginning to break up? c) Are the plaques less erythematous? d) Are there any signs of infection? folliculitis?
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Appendix B
Page 13 of 44
Table IVa Agents Implicated in Causing Photoallergy and Phototoxicity Therapeutic Class I. Analgesic Agents NSAIDs: celecoxib diclofenac diflunisal etodolac ibuprofen ketoprofen mefanamic acid meloxicam nabumetone naproxen oxaprozin piroxicam salicylates sulindac tiaprofenic acid II. Anticonvulsants carbamazepine gabapentin lamotrigine oxcarbazepine phenobarbital phenytoin topiramate valproic acid III. Antifungals griseofulvin itraconazole ketoconazole terconazole voriconazole IV. Antihistamines azatadine brompheniramine cetirizine cyproheptadine diphenhydramine loratadine promethazine trimeprazine triprolidine V. Antimalarials atovaquone/proguanil chloroquine
hydroxychloroquine mefloquine pyramethamine quinine VI. Antimicrobials Quinolones ciprofloxacin levofloxacin moxifloxacin norfloxacin ofloxacin Tetracyclines demeclocycline doxycycline minocycline tetracycline tigecycline Other azithromycin ceftazidime cefazolin dapsone isoniazid metronidazole nalidixic acid pyrazinamide sulfamethoxazole sulfasalazine sulfisoxazole trimethoprim VII. Antiretrovirals ritonavir saquinavir zalcitabine VIII. Antivirals amantadine acyclovir IX. Cardiovascular Agents Antihypertensives amlodipine benazepril captopril cilazapril diltiazem
enalapril felodipine fosinopril hydralazine lisinopril methyldopa minoxidil nifedipine perindopril quinapril ramipril sotalol trandolapril Cholesterol Lowering Agents atorvastatin fenofibrate fluvastatin lovastatin pravastatin simvastatin Diuretics acetazolamide amiloride bumetanide chlorthalidone ethacrynic acid furosemide hydrochlorothiazide indapamide metolazone spironolactone triamterene Other amiodarone disopyramide quinidine X. Cytotoxic Agents capecitabine dacarbazine (DTIC) epirubicin fluorouracil (5-FU) flutamide methotrexate procarbazine vinblastine
XI. Dermatologic Agents, Topical Sunscreens benzophenones cinnamates PABA Other benzocaine benzoyl peroxide chlorhexidine coal tar dibucaine hexachlorophene methoxsalen minoxidil silver sulfadiazine XII. Hormones corticosteroids estrogens oral contraceptives progestogens XIII. Hypoglycemics chlorpropamide gliclazide glimepiride glyburide tolbutamide XIV. Psychiatric Drugs Antipsychotics, Phenothiazines chlorpromazine fluphenazine methotrimeprazine perphenazine prochlorperazine promethazine trifluoperazine Antipsychotics, Other clozapine haloperidol loxapine
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 14 of 44
Table IVa – Agents Implicated in Causing Photoallergy and Phototoxicity Therapeutic Class Antipsychotics, Other (continued) olanzapine quetiapine risperidone thiothixene ziprasidone Tricyclic Antidepressants amitriptyline clomipramine desipramine doxepin imipramine maprotiline nortriptyline trimipramine
Selective Serotonin Reuptake Inhibitors citalopram escitalopram fluoxetine fluvoxamine paroxetine sertraline
Antidepressants, Other bupropion mirtazapine phenelzine trazodone venlafaxine Sedatives alprazolam chlordiazepoxide XV. Retinoids isotretinoin tretinoin
XVI. Vitamins pyridoxine (vitamin B6) vitamin A XVII. Miscellaneous cyclobenzaprine dantrolene fluorescein gold salts interferon beta olsalazine omeprazole pentosan selegiline sumatriptan tacrolimus
References: 1. Pierce SA. Drug induced photosensitivity. Capital District Health Authority, Halifax (NS) The Distillate 1997;23(4):13-6. 2. Drugs that increase photosensitivity. Pharmacist’s Letter/Prescriber’s Letter 2009;25(6):250606 3. Allen J. Drug-induced photosensitivity. Clin Pharm 1993;12:580-7. 4. Moore DE. Drug-induced cutaneous photosensitivity. Drug Safety 2002;25(5):345-372. 5. Tisdale JE, Miller DA, editors. Drug-induced diseases-prevention, detection and management. Detroit(MI): American Society of Health-System Pharmacists;2005. 6. DRUGDEX® System [intranet database]. Version 5.1. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. 7. Compendium of pharmaceuticals and specialties, online version (e-CPS). Canadian Pharmacists Association. Cited 2009 Nov. Available from: https://www.e-therapeutics.ca
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 15 of 44
Table IVb Agents Implicated in Causing Photoallergy and Phototoxicity Alphabetical Order acetazolamide acyclovir alprazolam amantadine amiloride amiodarone amitriptyline amlodipine atorvastatin atovaquone/proguanil azatadine azithromycin benazepril benzocaine benzophenones benzoyl peroxide brompheniramine bumetanide bupropion capecitabine captopril carbamazepine cefazolin celecoxib ceftazidime cetirizine chlordiazepoxide chlorhexidine chloroquine chlorpromazine chlorpropamide chlorthalidone cilazapril cinnamates ciprofloxacin citalopram clomipramine clozapine
coal tar corticosteroids cyclobenzaprine cyproheptadine dacarbazine (DTIC) dantrolene dapsone demeclocycline desipramine dibucaine diclofenac diflunisal diltiazem diphenhydramine disopyramide doxepin doxycycline enalapril epirubicin escitalopram estrogens ethacrynic acid etodolac felodipine fenofibrate fluorescein fluorouracil (5FU) fluoxetine fluphenazine flutamide fluvastatin fluvoxamine fosinopril furosemide gabapentin gliclazide
glimepiride glyburide gold salts griseofulvin haloperidol hexachlorophene hydralazine hydrochlorothiazide hydroxychloroquine ibuprofen imipramine indapamide interferon beta isoniazid isotretinoin itraconazole ketoconazole ketoprofen lamotrigine levofloxacin lisinopril loratadine lovastatin loxapine maprotiline mefanamic acid mefloquine meloxicam methotrexate methotrimeprazine methoxsalen methyldopa metolazone metronidazole minocycline minoxidil mirtazapine moxifloxacin
nabumetone nalidixic acid naproxen nifedipine norfloxacin nortriptyline ofloxacin olanzapine olsalazine omeprazole oral contraceptives oxaprozin oxcarbazepine PABA paroxetine pentosan perindopril perphenazine phenelzine phenobarbital phenytoin piroxicam pravastatin procarbazine prochlorperazine progestogens promethazine pyramethamine pyrazinamide pyridoxine (vitamin B6) quetiapine quinapril quinidine quinine ramipril risperidone ritonavir
salicylates saquinavir selegiline sertraline silver sulfadiazine simvastatin sotalol spironolactone sulfamethoxazole sulfasalazine sulfisoxazole sulindac sumatriptan terconazole tetracycline thiothixene tiaprofenic acid tigecycline tolbutamide topiramate trandolapril trazodone tretinoin triamterene trifluoperazine trimeprazine trimethoprim trimipramine triprolidine valproic acid venlafaxine vinblastine vitamin A voriconazole zalcitabine ziprasidone
References: 1. Pierce SA. Drug induced photosensitivity. Capital District Health Authority, Halifax (NS). The Distillate 1997;23(4):13-6. 2. Drugs that increase photosensitivity. Pharmacist’s Letter/Prescriber’s Letter 2009;25(6):250606 3. Allen J. Drug-induced photosensitivity. Clin Pharm 1993;12:580-7. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 16 of 44
4. Moore DE. Drug-induced cutaneous photosensitivity. Drug Safety 2002;25(5):345-372. 5. Tisdale JE, Miller DA, editors. Drug-induced diseases-prevention, detection and management.. Detroit(MI): American Society of Health-System Pharmacists;2005. 6. DRUGDEX® System [intranet database]. Version 5.1. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. 7. Compendium of pharmaceuticals and specialties, online version (e-CPS). Canadian Pharmacists Association. Cited 2009 Nov. Available from: https://www.e-therapeutics.ca
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 17 of 44
APPENDIX C Skin Type Estimation There are two methods of establishing a starting dose for UVL – skin type estimation and MED testing. At this centre the skin type method is utilized. The skin type approach is an estimate of the patient’s ability to tolerate ultraviolet light. This method is the most widely used and dosing is quite accurate as long as the correct skin type has been determined. Looking at the buttocks, abdomen or under the arms will provide a more accurate picture of the patient’s true skin type.
Skin Type Type I
Type II
Pigmentation & Erythema Genetic History History Has very poor availability to Very fair skin, freckling evident; tan; burns easily and severely blue, green or grey eye color; blonde, and then peels red or light brown hair; unexposed skin is white; Celtic, Northern European heritage Tans minimally or lightly Fair skin; unexposed skin is white; blue, following exposure; usually green, grey or brown eye color; blonde, burns easily resulting in a red or brown hair; German, European painful burn heritage
Type III
Tans gradually following exposure; burns moderately
Unexposed skin is white; hair and eye color usually brown; Southern European heritage
Type IV
Burns minimally; tans well with initial exposure
Type V
Tans easily and profusely; rarely burns
Type VI
Deeply pigmented; never burns
White or light brown skin color; unexposed skin is white or light brown; dark hair and eye color; Mediterranean, Oriental or Hispanic heritage Brown skin; unexposed skin is brown; African, Native American, East Indian, Hispanic heritage Black skin; unexposed skin is black; African, Native American , East Indian, Hispanic heritage
* Vitiligo is always considered to be Skin Type I Reference: Leach, E., Morgan, P., McClelland, P., Shelk, J. Basic Principles of Photobiology and Photochemistry for Nurse Phototherapists and Phototechnicians. In: Dermatology Nurses’ Association 27th Annual Convention, Fundamentals of Photobiology: The Joan Shelk Memorial Workshop March, 2009 This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 18 of 44
APPENDIX D Guidelines to Erythema Assessment Most often, subsequent UVL treatments are based on the patient’s response to the previous one. The major determining factor is whether the previous treatment produced erythema. The onset and duration of Broad Band UVB induced erythema is quite different when compared to erythema caused by UVA. Erythema Onset Normal Peak Normal Duration Extreme peak Extreme Duration
UVB 2-6 hours 12-18 hours 24-48 hours 14-20 hours 1-2 months
UVA 24-36 hours 48-72 hours one week Over 96 hours 3-6 months
Erythema is the major short-term reaction to UVL. The patient is assessed for erythema response at every visit. Proper documentation of erythema includes: onset, erythema grade, location, discomfort, duration and possible reason for erythema. The erythemal response is a guide used to determine if an increase, decrease, discontinuation or pause in therapy is required. Erythema response is graded as follows: Grade 0 No erythema Grade 1 Minimally perceptible erythema – slight pink. The lesion is a macule (less than 1cm) or patch greater than 1cm) with alteration of skin color. It is completely flat. Grade 2 Marked erythema without edema (swelling). Grade 3 Fiery erythema with edema. The lesion is elevated above the skin surface. Grade 4 Fiery erythema with edema and blistering of the skin. It is possible to have partial grades of erythema. Patients often have erythema that is a bit more than slightly pink yet not quite red enough to be classified as a grade 2. This is classified as a grade 1½. Location is described as 1) localized 2) generalized Arms and legs often require twice the amount of light as that required on the torso, to produce the same therapeutic effect. As a result, patients tend to experience symptomatic This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 19 of 44
erythema primarily on the torso and face. If erythema is localized and can be protected with shielding, the rest of the body should be treated. Proper documentation will explain why the patient is being treated despite the presence of symptomatic erythema. If the patient presents with generalized (total body) symptomatic erythema, documentation will explain why no treatment is given. Discomfort should be rated as 1) mild 2) moderate 3) severe Because each patient interprets symptomatic erythema differently, it is important to note the degree of discomfort. For example, a patient with grade 2 erythema may deny any discomfort while another patient with a grade 1 will describe moderate discomfort. Careful attention to this detail will help determine how aggressively each patient can be treated with UVL. Duration is rated as 1) less than 24 hours 2) more than 48 hours Most patients clear more rapidly when a non-painful erythema is achieved with UVL treatment. How long this erythema lasts is important. ¾ If erythema with no pain is resolved within 24 hours then repeat dose ¾ If erythema with pain is resolved within 24 hours then go back to previous dose prior to erythema ¾ If erythema with pain is unresolved after 24 hours then reduce dose by 25% Painful or not, erythema lasting more than 2 days necessitates a decrease in the subsequent treatment dose. The patient may have to be reviewed by the dermatologist.
Possible Reason for erythema:
inappropriate UVL dose last treatment incorrect skin type incorrect equipment metering patient position in phototherapy booth omission or position change of shielding change in patient’s medication concurrent natural sun exposure
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 20 of 44
Erythema Assessment and Subsequent Treatment Grade 0
Increase as per skin type guidelines.
Grade 1
Hold dose constant and do not increase until erythema is resolved. Localized erythema (i.e. breasts) can be shielded by sunscreen or drape until resolved and dosing can be cautiously increased as per skin type.
Grade 2
Stop treatment until the entire erythema has resolved. Explain to the patient that the burning effects may take 1-2 weeks to fully resolve. Once erythema has resolved, the starting dose should go back to at least the dose prior to the burn or may be decreased by 10-25% depending on the extent of the erythema and the individual patient’s history. The date of the last treatment should also be noted and further increases should be on the conservative side.
Grade 3
Do not treat. Notify physician. Have patient seen by physician for skin assessment and new orders. Once erythema has resolved, the patient’s skin should be reassessed, and time of last treatment assessed to determine the reduction in the dose. Dose may be decreased by 10-25% depending on the extent of the erythema and the individual patient’s history.
Grade 4
Same as for Grade 3.
Adapted from the Guidelines from the DNA Phototherapy Administration Symposium, 1999 and the 27th Annual DNA Conference Fundamentals of Phototherapy: the Joan Shelk Memorial Workshop, March, 2009.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 21 of 44
APPENDIX E Guidelines for Pruritus Assessment Pruritus may be minimized and in most cases avoided if certain guidelines are followed. Pruritus can be assessed and described by grades. The pruritic response is a guide used to determine increases, decreases, holding or stopping therapy. Grade 0
No pruritus
Grade 1
Mild pruritus
Grade 2
Severe pruritus
Grade 3
Intractable pruritus (PUVA itch)- unrelenting burning itch 24 hours/day even when not receiving light treatment.
Pruritic Assessment and Subsequent Treatment Grade 0
Increase UVA as per skin type.
Grade 1
Generally caused by dry skin. Continue to increase UVA as per skin type using lower dosing schedule. Encourage frequent applications of bland emollients.
Grade 2
Stop UVA therapy a few days to assess if light-induced or disease poorly controlled. If light –induced, reduce 2-3 joules and possibly decrease frequency. Systemic antihistamines can be ordered by the physician. Care should be taken to explain the side effects of these medications (i.e. drowsiness). Notify dermatologist if problem persists.
Grade 3 - Localized: • shield the specific areas with cloth barriers. • Keep light constant. - Generalized: • Stop treatment until the itching and pain are totally resolved. • Explain that it may take weeks to resolve. • Once pruritus has resolved, resume light 2-3 joules below the pruritic dose and follow with conservative increases. • Emollients are helpful for dryness, but are not effective in reducing the itch. Systemic antihistamines are not helpful in PUVA itch. • Dermatologist to review patient. Guidelines from the DNA Phototherapy Administration Symposium, 1999. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 22 of 44
APPENDIX F
Assessment of Response to UVL Therapy It is important to assess and document the patient’s response to UVL treatment. Using the grading criteria below, the physician and phototherapy technician can take appropriate measures to maximize the benefits from this form of therapy for each patient. Grade -1
Dermatology condition worse.
Grade 0
No change
Grade 1
Minimal improvement – slightly less scale and/or erythema
Grade 2
Definite improvement – partial flattening of all plaques – less scaling and less erythema.
Grade 3
Considerable improvement – nearly complete flattening of all plaques but borders of plaques still palpable.
Grade 4
Clearing; complete flattening of plaques including borders; plaques may be outlined by pigmentation.
Response to UVL Therapy and Subsequent Treatment Grade –1
Dermatology condition worsening. New patients may flare until the dose of UVL is sufficient to begin suppressing the disease. Another and more serious cause of a flare is the inability of the patient to tolerate light. In this case, further treatment will only exacerbate the problem. If there is any question, discontinue treatment until the patient is seen by the physician.
Grade 0
No change. Continue to increase according to protocol if no erythema has occurred. For patients who continue to show little or no signs of improvement, other treatment modalities should be considered.
Grade 1
Minimal improvement. Continue therapy and if no erythema has occurred, consider using a more aggressive protocol.
Grade 2& 3 Continue therapy as per protocol. Grade 4
Consider maintenance.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 23 of 44
APPENDIX G
Treatment Protocol for Broad Band UVB
Initial Dose Determination via Skin Type
Skin Type
Suberythemal (66% E1)
E1
I II III IV V VI
24mj 40mj 48mj 56mj 64mj 72mj
36mj 60mj 72mj 84mj 96mj 108mj
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 24 of 44
UVB REGIME for Subsequent Treatment – SKIN TYPE I-VI Skin Type I Skin Type II Skin Type III Skin Type IV Skin Type V 24mj 40mj 48mj 56mj 64mj 26mj 45mj 54mj 63mj 72mj 29mj 51mj 61mj 71mj 81mj 32mj 57mj 68mj 79mj 91mj 35mj 64mj 77mj 89mj 102mj 38mj 72mj 86mj 100mj 115mj 42mj 81mj 97mj 112mj 129mj 46mj 91mj 109mj 126mj 145mj 51mj 102mj 123mj 142mj 163mj 56mj 115mj 138mj 160mj 184mj 62mj 129mj 156mj 180mj 207mj 68mj 145mj 175mj 202mj 232mj 75mj 163mj 197mj 228mj 240mj (max) 82mj 184mj 222mj 240mj (max) 264mj 90mj 207mj 240mj (max) 264mj 290mj 99mj 232mj 264mj 290mj 319mj 109mj 240mj (max) 290mj 319mj 350mj 119mj 319mj 350mj 385mj 131mj 350mj 385mj 423mj 144mj 385mj 423mj 465mj 158mj 423mj 465mj 500mj 174mj 465mj 500mj 191mj 500mj 210mj 231mj 240mj (max) * Shaded areas: If necessary with physician’s order, treatment may be increased up to maximum of 500mj
Skin Type VI 72mj 81mj 91mj 102mj 115mj 129mj 145mj 163mj 184mj 207mj 232mj 240mj (max) 264mj 290mj 319mj 350mj 385mj 423mj 465mj 500mj
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 25 of 44
Subsequent Treatment for Broad Band UVB Assess erythema as per Appendix D and follow guidelines for specific grade of erythema. Assess pruritus as per Appendix E and follow guidelines for specific grade of pruritus. Assess response to UVL therapy as per Appendix F and follow guidelines for specific grade of response.
Dosage Adjustments for Missed Appointments It is challenging to determine dosages for patients who have missed one or more treatments. The following protocol is designed to help prevent undesirable erythema while delivering enough UVB to be therapeutic. Missed days: 1-4 days 5-7 days 8-10 days > 10 days
Hold the same dose. Decrease dose by 25% Decrease dose by 50% Decrease dose by 75% or give initial dose
Maintenance Schedule for Broad Band UVB The goal of UVB therapy is clearance of the skin using the least total number of millijoules possible. Once clearing has been achieved, the frequency of treatments can be gradually reduced. The patient’s response will determine how rapidly the number of treatments per week may be decreased. UVB offers photoprotection by increasing the melanin in the epidermis and thickening the top layer of skin. Protection is lost as old cells are sloughed off and replaced by new ones. As the average skin cell’s life is approximately 28 days, UVB protection may rapidly be lost. Because of this, it is difficult to extend maintenance therapy beyond 7 to 10 days without developing undesirable erythema. If the patient begins potentially photosensitizing medications during the course of treatment decrease the dose by 50% or go back to initial dose, whichever is greater.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 26 of 44
APPENDIX H TREATMENT PROTOCOLS for Narrow Band UVB The protocol used at the QEII HSC is a combination of that outlined in the book “Phototherapy Treatment Protocols for Psoriasis and other Phototherapy Responsive Dermatoses” by M.D. Zanolli, MD and S.R.Feldman, MD and the protocol developed by Leone Dermatology Centre. 1. The initial NBUVB dose (mj/cm²) will be based on the patient’s skin type determination. Skin Type Initial Dose Increase Increase Estimated Goal (3 Rx’s/week) (5 Rx’s/week) (4 x’s initial dose) I 130mj 15mj 10mj 520mj II 220 mj 25mj 15mj 880mj III 260mj 40mj 20mj 1040mj IV 330mj 45mj 25mj 1320mj V 350mj 60mj 30mj 1400mj VI 400mj 65mj 30mj 1600mj Vitiligo 170mj 30mj (unknown) 2. The number of treatments will vary from 1 to 5 times a week as per physician’s orders. 3. All measurements ie. mj, seconds and total doses will be recorded on a daily basis. 4. Example of treatment: Initial dose for patient with skin type I receiving 3 treatments/week is 130mj. The next Rx dose would be 145mj (increase of 15mj/Rx). And so on until reaching goal of 4x’s initial dose. Dosage adjustment protocol for missed treatments: Time missed 1-7 days 8-11 days 12-14 days 15-20 days 28 or more
give % of last treatment Increase per standard protocol 100% (no conditioning lost) Decrease by 3 treatments worth 75% (25% conditioning lost) Start over at initial does (100% of conditioning may be lost) NB. Conditioning lasts longer than Broad Band UVB, therefore, a slightly more aggressive schedule is permitted for missed treatments.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 27 of 44
APPENDIX I Treatment Protocol for UVA Initial Dosing and Subsequent Dose Ranges The increments of UVA dosing are determined by the patient’s skin type. The chart below lists the initial doses and increments according to the various skin types. Response to light varies within the skin types, and ranges are listed for safety and efficacy. Skin Type I II III IV V VI
Initial Doses (J/cm2) 0.5-1.5 1.0-2.5 1.5-3.5 2.0-4.5 2.5-5.5 3.0-6.5
Subsequent Doses (J/cm2) 0.25-0.50 0.50-1.0 0.50-1.5 1.0-2.0 1.5-2.5 2.5-3.0
If patient starts sensitizing medications during the course of treatment, decrease the dose by 50% or go back to initial dose, whichever is greater. Dose adjustments for missed appointments If patient missed 1-2 weeks then use the same dose as last treatment. Continue to increase by 0.5 J/cm² per visit as per schedule. If patient missed 3 weeks then decrease dose by 25%. If patient is at maintenance dose, they can come as infrequently as once a month but no less. If patient on once monthly treatments has missed their appointment and comes at 6-8 weeks then decrease the dose by 50% at 6 weeks, 60% at 7 weeks, and 70% at 8 weeks or use initial dose which ever is greater.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 28 of 44
Example of 9 week treatment with UVA increasing dose by 0.5J/cm² per visit
Week
1
2
3
4
5
6
7
8
9
UVA regime 1.0 J/cm² 1.5 J/cm² 2.0J/cm² Cumulative joules 4.5 2.5 J/cm² 3.0 J/cm² 3.5 J/cm² Cumulative joules 13.5 4.0 J/cm² 4.5 J/cm² 5.0J/cm² Cumulative joules 27.0 5.5 J/cm² 6.0 J/cm² 6.5J/cm² Cumulative joules 45.0 7.0 J/cm² 7.5 J/cm² 8.0 J/cm² Cumulative joules 67.5 8.5 J/cm² 9.0 J/cm² 9.5 J/cm² Cumulative joules 94.5 10.0 J/cm² 10.5 J/cm² 11.0 J/cm² Cumulative joules 126.0 11.5 J/cm² 12.0 J/cm² 12.5 J/cm² Cumulative joules 162.0 13.0 J/cm² 13.5 J/cm² 14.0 J/cm² Cumulative joules 202.5
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 29 of 44
APPENDIX J
PUVA Photochemotherapy ( Psoralen Plus Ultraviolet A) UVA radiation will not by itself cause erythema or pigmentation except with extremely large doses. However, in the presence of a photosensitizer such as psoralen compounds, the longwave UVL spectrum becomes an excellent therapeutic tool. Photochemotherapy is the therapeutic use of radiation in combination with a photosensitizing chemical. It currently involves the use of psoralens and UVA radiation. Treatment may be delivered with systemic, bath/soak or topical psoralens and may involve partial or wholebody exposure. Systemic or Oral Psoralen 1. Oxsoralen Ultra (8-methyoxypsoralen) is to be ingested by the patient at least 1-2 hours prior to arrival at the center. Treatments may be initiated from 1-1½ to 2 hours after ingestion. 2. Dosage of the Oxsoralen Ultra tablets is dependent on the orders of the attending physician. The standard dosage is 0.5-0.6 mg/kg. 3. Verify with the patient the time and number of tablets that were taken to ensure that the patient has taken the medication correctly. 4. An ophthalmology examination should be performed prior to and every 6 months during Oral PUVA therapy. 5. Laboratory monitoring is done at baseline and every 6 months as necessary for Oral PUVA. 6. Follow instructions outlined in “All PUVA Therapy” p.30. Psoralen Bath or Soak 1. Dilute 8-methoxypsoralen lotion in 2 liters of warm water in a basin for hand or foot soak or dilute lotion into a tub, half full of water. See table below for lotion concentration and amounts. 8Methoxypsoralen Concentration 0.5% 1%
mg/ml
5 mg/ml 10 mg/ml
Quantity for hand or foot soak 2 mls 1 ml
Quantity for tub 24 mls 12.5 mls
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 30 of 44
2. Soak the patient’s hands and/ or feet and/or body for 10 minutes. Hand held timer to be kept with the patient during the soaking procedure. Dry the skin by patting the surface with a dry towel. Wrap the wrist with multiple layers of cloth to provide protection from the UVA light for hand PUVA. Depending upon the location of the disease, sunblocks are used to protect the unaffected skin. The PUVA light has to be administered to the patient within 25 minutes of their soak. 3. Follow instructions outlined in “All PUVA Therapy” below. Topical Psoralen 1. The pharmacy will prepare Oxsoralen Solution 0.1% in soft paraffin. 2. The patient will apply the ointment to the psoriatic plaques only. Patients must be cautioned to avoid contact of the ointment on normal skin. This may result in severe sunburn to the normal skin. 3. The patient will leave the ointment on the skin for 1-2 hours before receiving the light therapy. This can be applied at home prior to their appointment time. 4. Follow instructions outlined in “All PUVA Therapy” below. All PUVA Therapy 1. Follow general procedure for UVA/UVB and NBUVB light treatment on page #3 of the policy. 2. To determine initial dose for UVA light treatment refer to Skin Type Estimation, Appendix C and Treatment Protocol for UVA, Appendix I. 3. Following the treatment, the patient must thoroughly wash hands and/or feet and/or bath to remove any medication residue on the surface of the skin. UVA/UVB sunblock is provided for the patient as a precautionary measure to avoid additional UVA exposure that day. 4. Instruct the patient to avoid excessive sunlight for the remainder of the day. A burn may not be evident until 48 hours following treatment. Treatments aren’t usually given on two consecutive days. This allows the technician to observe accurately for erythema. Patient instructions re Oral PUVA therapy •
Take exact amount of the prescribed drug 1 ½ - 2 hours prior to light treatment.
•
On the day of light treatment there must be no sun exposure. A sunscreen with SPF 30 or higher must be worn.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 31 of 44
•
Excessive sun exposure is to be avoided on other days.
•
Medication should be taken with milk to avoid nausea.
•
If medication is not taken on time, the clinic /phototherapist should be notified as the treatment time may have to be adjusted.
•
Wrap-around UVA sunglasses should be worn for 24 hours following light treatment. This is not necessary after sundown or if indoors unless sitting by a window. Sun exposure puts patients at risk for developing cataracts.
Subsequent Treatments for all PUVA Therapy 1. The frequency of PUVA treatments is 2 or 3 times a week unless otherwise ordered by the physician. If more than 3 times a week has been ordered then the request must be accompanied by special instructions as to the advancement of the dose of UVA light. 2. On subsequent visits the patient will be assessed for grade of erythema, discomfort, duration and location as per Appendix D, pruritus as per Appendix E, and response to therapy as per Appendix F. Subsequent treatments are based on these assessments. 3. Check patients for: skin itchiness, skin rash, headache, nervousness, nausea, leg cramps, dizziness, mental depression, sleeplessness. The two most important problems to watch for are nausea and PUVA itch. 4. For dose increases follow treatment protocol for UVA Appendix I. e) PUVA should be done 2-3 times weekly for best results. Treatments can be tapered to maintenance after an acceptable response has occurred. Rule: The starting maintenance dose is held constant at the last clearance dose of UVA radiation. NB: Recommendations for PUVA therapy: • no more than 250 treatments/ life time • no longer than 10 years of treatment • treatments not to exceed life time dose of 1500 J/cm² • exceptions occur when there is no other treatment for the patient (Stern, Nichols, Vakeva NEJM, 1997)
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 32 of 44
Certification Test 1. The most common reaction from Broad Band UVB is? a. b. c. d. e.
Polymorphous light reaction Erythema Pruritus Vesiculation Bullae
2. The starting dose for UVB in Nova Scotia is determined by: a. b. c. d. e.
Eye colour MED Number of sunburns in the past Skin type Hair colour
3. The standard increase for Broad Band UVB is determined by: a. b. c. d. e.
Percentage by skin type 5 mj per visit .5 mj/cm² per treatment 10 mj per visit 100 mj per visit
4. What is the wavelength of Broad Band UVB radiation? a. b. c. d. e.
320-400 nanometers 290-320 nanometers 150-200 nanometers 50-100 nanometers < 200 nanometers
5. Broad Band/ Narrow Band UVB phototherapy can safely be administered to: a. b. c. d. e.
Pregnant women Nursing mothers Children All of the above None of the above
6. Which statement is correct regarding millijoules and time: a. Millijoules and time both represent a universal language for dosing This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 33 of 44
b. Millijoules are a constant factor, whereas time is directly related to the energy output of the booth c. As the energy output of a booth decreases, both millijoules and time increase d. As the energy output of a booth increases, milijoules will increase and time will decrease 7. Which area(s) of the skin will provide the most accurate “skin type”? a. b. c. d.
Hands, forearms and buttocks Buttocks, back and under the arms Abdomen, forearms and buttocks Buttocks, abdomen and under the arms
8. MED is defined as: a. b. c. d.
The average amount of ultraviolet light needed to produce a sunburn The amount of ultraviolet light needed to produce a tan The smallest amount of ultraviolet light needed to produce a slight sunburn The amount of ultraviolet light needed to cause blistering
9. The reason Broad Band UVB doses must be adjusted when four or more “clearing” treatments are missed: a. b. c. d.
Photoprotection for UVB may rapidly be lost when treatments are missed Patient will want to spend less time in the booth Patient’s skin will be too thickened to respond to normal dosing None of the above
10. What can contribute to a flare of psoriasis during UVB treatment? a. b. c. d.
Streptococcal infection Inability of the patient to tolerate UVB UVB dose is not yet sufficient to begin suppressing the disease All of the above
11. The time required between “clearing” UVB treatments is: a. b. c. d.
12 hours 24 hours 36 hours 48 hours
12. Erythema from a UVB treatment will usually show up within: a. 1 hour b. 6 hours c. 24 hours This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 34 of 44
d. one week 13. Normal erythema from a UVB treatment will usually last: a. b. c. d.
12-24 hours 24-96 hours one week none of the above
14. Which grade of erythema is relatively acceptable from Broad Band/Narrow Band UVB? a. b. c. d. e.
1 2 3 4 none of the above
15. A patient with a grade 1 erythema may: a. b. c. d. e. f.
Never be treated Be given the same dose as the last time Be given a somewhat lesser dose than the last time Admitted to the hospital B or C A or D
16. A “clearing” patient who misses 14 days of treatment should have their treatment decreased by what percent of the last Broad Band UVB dose? a. b. c. d.
None 50% 75% or initial dose whichever is greater 25%
17. Proper dose adjustment for a patient receiving Narrow Band UVB who has had a 12 day break since the last treatment is: a. b. c. d.
Decrease dose by 50% Increase by standard protocol Decrease by 3 treatment’s worth Hold dose the same
18. What skin type(s) is/are expected to clear in the 240-500 millijoule range? a. I b. II c. III This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 35 of 44
d. IV 19. Patients receiving total body UVL treatment with localized erythema should: a. b. c. d. e.
Have full body dose increased Have full body dose increased with erythema shielded Be advised to skip a treatment See the MD Have time decreased by 100 millijoules
20. Severe erythema should be treated with: a. b. c. d. e.
Aveeno baths Tylenol for discomfort Cool compresses Assessment by the Dermatologist All of the above
21. The wavelengths which are of the greatest photobiologic importance in phototherapy are: a. b. c. d.
260 nm – 290 nm 290 nm – 320 nm 290 nm – 400 nm 320 nm – 400 nm
22. Which waveband of UV radiation is mainly responsible for the erythema reaction following exposure to sun? a. b. c. d.
UVA UVB UVC UVA and UVC
23. The wavelengths necessary to produce a photobiologic response in photochemotherapy are: a. b. c. d.
230 nm – 260 nm 260 nm – 290 nm 290 nm – 320 nm 320 nm – 400 nm
24. UVB is how many times more likely to produce erythema than UVA? a. 10 times b. 100 times c. 500 times This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 36 of 44
d. 1,000 times 25. Exposure dose is equal to: a. b. c. d.
Joules x time Watts x time Intensity x time Millijoules x time
26. The skin has 3 distinct layers. They include all of the following except: a. b. c. d.
Dermis Epidermis Fascia Subcutaneous tissue
27. Ingredients found in sunscreen that block in both the UVA and UVB range include all of the following except: a. b. c. d.
Cinnamates Benzophenones Propylene glycol Salicylates
28. The initials of “SPF” stand for: a. b. c. d.
Sun protection fun Sun protection formula Sun protection factor Sun protection function
29. If a sunscreen product has the # 30 after the initials “SPF”, this indicates: a. b. c. d.
Protection for 30 times the individual’s MED Protection for only 30 minutes Protection for 30 hours Protection until the sun sets
30. Chronic sun damaged skin clinically has all of these characteristics except: a. b. c. d. e.
Dry skin Hyperpigmentation Loss of elasticity Loss of adipose tissue Hypopigmentation
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 37 of 44
31. The wavelength used for germicidal radiation is: a. b. c. d.
UVA UVC UVB Ionizing radiation
32. A radiometer performs all of the following except: a. b. c. d.
Determines the wavelengths of an artificial light source Reads the type of wavelengths of the light bulbs in a unit Measures the output of power of the lamp Calculates the number of hours a lamp has burned
33. Increased melanin synthesis produces: a. b. c. d. e.
Erythema Hyperpigmentation Pruritus Hypopigmentation Diabetes
34. The most common, but rare, side effect of sun protection agents is: a. b. c. d. e.
Allergic contact dermatitis Anaphylaxis Wheezing Hypopigmentation Nausea
35. If a MED is ordered prior to starting phototherapy, where should the template be placed? a. b. c. d. e.
Arms Legs Back Buttocks Soles of the feet
36. A Minimal Phototoxic Dose (MPD) should be evaluated how many hours after exposure? a. b. c. d.
6-12 12-24 24-48 48-72
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 38 of 44
37. The name of the pigmentary change seen in patients undergoing PUVA is: a. b. c. d. e.
Lentigo Telangiectasia Solar elastosis Nevus Melanoma
38. The output of the phototherapy UVA/UVB lamps is documented as: a. b. c. d. e.
Milliwatts/cm² Joules/cm² Millijoules/cm² Joules/milliwatts Joules/wavelength
39. What is the wavelength of the Narrow Band UVB lamps? a. b. c. d. e.
260 295 300 311 400
40. A patient is receiving bath PUVA. What time frame is required between the time they take their bath and then receive UVA therapy? a. b. c. d. e.
5-10 minutes 10-15 minutes 20-25 minutes 25-35 minutes 35-40 minutes
41. A patient tells you that they usually tan and only rarely ever burn. What is their skin type? a. b. c. d. e. f.
I II III IV V VI
42. You are assessing a patient for the first time. They have never received UVL in the past. You have five categories to explore in this assessment. They include all of the following except: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
a. b. c. d. e.
Page 39 of 44
Subjective data Clinical examination Objective data Plan Implementation and evaluation
43. Place the following wavelengths in the right order: a. b. c. d. e. f. g.
Infared X-rays Ultraviolet Cosmic rays Radio waves Visible Gamma rays
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 40 of 44
TEST ANSWERS 1. B 2. D 3. A 4. B 5. D 6. B 7. D 8. C 9. A 10. D 11. A 12. B 13. A 14. A 15. E 16. C 17. C 18. C&D 19. B 20. E 21. C 22. B This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 41 of 44
23. D 24. D 25. C 26. C 27. C 28. C 29. A 30. D 31. B 32. D 33. B 34. A 35. D 36. D 37. A 38. A 39. D 40. C 41. D 42. B 43. D,G,B,C,F,A,E. or E,A,F,C,B,G,D.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 42 of 44
CAPITAL HEALTH NURSING DIVISION PROFICIENCY STANDARDS SKILLS CHECKLIST
TITLE: Phototherapy Treatment NAME: ______________________________________________________________ YES
NO
1. Check physician order. 2. Complete patient assessment. 3. Explain procedure to the patient. 4. Check patient’s consent for treatment. 5. Determine the patient’s skin type. 6. Assess patient for erythema on subsequent visits 7. Assess patient for pruritus 8. Assess patient response to UVL therapy 9. Determine the treatment dose according to skin type and treatment Protocol. 10. Pre-heat light unit. 11. Prepare patient for light treatment: • Have patient remove appropriate clothing • Apply protective shields e.g. sunblock, eye goggles, G-string 12. Set treatment and fail safe timers. 13. Administer UVL therapy as per specific treatment protocol. 14. Document treatment in the patient record. 15. Ongoing patient education. 16. Report problems to attending physician.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 43 of 44
CAPITAL HEALTH NURSING DIVISION PROFICIENCY STANDARDS SKILLS CHECKLIST Diagnostic Tests in Phototherapy TITLE: Photosensitivity Testing NAME: ______________________________________________________________ YES
NO
1. Review physician’s letter of referral. 2. Complete patient assessment. 3. Explain procedure to the patient. 4. Check patient’s consent for treatment. 5. Choose the test site. If requested, prepare the test area in the same way as the area to be treated. 6. Place the test stencil/sleeve/garment on the patient in the area to be tested. 7. Position the patient in the desired pose. 8. Cover (shield) all exposed areas except the test site. 9. Ensure goggles are properly in place 10. Pre-heat light unit. 11. Set treatment and fail safe timers. 12. Radiate, mark and cover each window area until all windows have been exposed with the desired time or dose. 13. Instruct patient to inspect the skin for erythema 6 hours post test. If no response, continue to check the skin hourly until 12 hours have past. 14. Document the test in the patient record. 15. For UVB sensitivity, read test (Dermatologist or phototherapy technician) for MED 24 hours post test. 16. For UVA sensitivity, read test area at 24, 48 and 96 hours post test. 17. Document test results in the patient record.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Phototherapy Learning Module CC 50-020
Page 44 of 44
CAPITAL HEALTH NURSING DIVISION PROFICIENCY STANDARDS SKILLS CHECKLIST Diagnostic Tests in Phototherapy TITLE: Photopatch Testing NAME: ______________________________________________________________ YES
NO
1. Check physician’s order. 2. Complete patient assessment. 3. Explain procedure to the patient. 4. Check patient’s consent for treatment. 5. Pre-heat light unit. 6 Set treatment and fail safe timers. 7. Clinic nurse applies 2 identical sets of photoantigens to the patient: one set to each side of the upper portion of the patient’s back. 8. Place patch testing garment (with windows cut in it) on the patient. 9. Deliver grade doses (eight to ten exposures) of UVB to previously unexposed skin sites in each window area approximately 1 cm². 10. Deliver UVA test dose (usually 10 J/ cm²) to a single site on the opposite side the UVB test approx. 1 cm². 11. Document test in the patient record. 12. Day 2: Evaluate phototest sites for erythema. If erythema is present at UVA test site, titrate UVA doses (using doses of 1 through 10 joules) to determine the appropriate UVA photopatch dose. Read on Day 3. If no erythema response at UVA test site, continue with photopatch test. 13. Remove both sets of antigens and mark skin areas. Read all sites for contact allergy or irritancy. 14. Cover one set of patches (dark control) with light- opaque material and expose the other set to the UVA dose (10J/ cm²). 15. Cover irradiated area with light-opaque material as well. 16. Day 4: Read test. Schedule second reading of this test at 72 hours, 96 hours or 1week post test. 17. Document test results in the patient record.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
